Session 10: Tumor/
Pediatrics
Fredag den 25. oktober
09:00 – 10:30
lokale: Stockholm/Copenhagen
Chairmen: Thomas Baad-Hansen / Bjarne Møller-Madsen
94. The Prevalence and Prognostic Impact of Comorbidity in Soft Tissue Sarcoma: A Population-Based Cohort Study
Katja Maretty-Nielsen, Ninna Aggerholm-Pedersen, Akmal Safwat, Steen Baerentzen, Alma Pedersen, Johnny Keller
Department of Experimental Clinical Oncology, Aarhus University Hospital; Department of Oncology, Aarhus University Hospital; Department of Pathology, Aarhus University Hospital; Department of Clinical Epidemiology, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital
Background: The incidence of soft tissue sarcoma
increases with increasing age, and more
elderly patients with comorbidity is expected
in the future. Comorbidity is an important
prognostic factor for survival in other
cancers. The prevalence and significance of
comorbidity has not yet been investigated in
a larger population-based series of soft
tissue sarcoma.
Purpose / Aim of Study: The aim of this study was to estimate the
prevalence and impact of comorbidity on
mortality in soft tissue sarcoma patients.
Materials and Methods: 1210 adult patients with soft tissue
sarcoma in the extremities or trunk were
identified through the Aarhus Sarcoma
Registry, a validated population-based
database. Comorbidity data was obtained
through the National Patient Registry, and
a Charlson Comorbidity score was
calculated for each patient. The
prevalence was assessed overall, as
well as according to age and year of
diagnosis. The prognostic impact of
comorbidity on overall and disease-
specific mortality was estimated uni- and
multivariately using proportional hazard
models.
Findings / Results: The overall comorbidity prevalence was
25%. The prevalence increased with
increasing age, and patients with
comorbidity had a larger proportion of
adverse prognostic factors compared to
patients without comorbidity. The 5-year
disease-specific mortality was 26% (95% CI
24-29) for patients without comorbidity,
compared to 33% (95% CI 24-42), 41%
(95% CI 32-50), and 44% (95% CI 33-55) for
patients with mild, moderate, and severe
comorbidity, respectively. After adjusting for
important prognostic factors, comorbidity
was associated with increased overall and
disease-specific mortality.
Conclusions: Patients with comorbidity had significantly
increased overall and disease-specific
mortality compared to patients without
comorbidity, even when adjusting for known
important prognostic factors.
95. Predictors for functional outcome and health related quality of life following limb sparing surgery for soft-tissue sarcomas
Casper Sæbye, Hanna Maria Fuglø, Tine Nymark, Akmal Safwat, Michael Mørk Petersen, Johnny Keller
Department of Experimental Clinical Oncology, Sarcoma Centre of Aarhus University Hospital; Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital; Department of Oncology, Sarcoma Centre of Aarhus University Hospital; Department of Orthopedic Surgery E5, Sarcoma Centre of Aarhus University Hospital
Background: Patient function can be conceptualized
by different clinical aspects such as
disability, impaired mobility and health
status.
Purpose / Aim of Study: To identify tumour and patient related
predictors (age, gender, depth, size,
malignancy, comorbidity, location and
radiotherapy) for functional outcome
and quality of life after limb sparing
surgery in sarcoma patients.
Materials and Methods: The study included 131 patients (mean
age = 58, F/M = 57/74), that were
treated with limb-sparring surgery
without bone-resection for soft tissue
sarcomas in 3 Danish sarcoma centers
during the period 1/1-2009 to 31/12-
2011. Patients were asked to
participate at least 1 year after surgery,
and patients that had experienced
local recurrence or metastatic disease
were excluded. Functional disability
was measured by the Toronto
Extremity Salvage Score (TESS), and
functional impairment by the
Musculoskeletal Tumour Society Score
(MSTS), and Quality of Life by EORTC
QLQ-C30. A questionnaire was used
to gather relevant data about
physiotherapy.
Statistics: Multivariate logistic
regression analysis with calculation of
odds ratio (OR).
Findings / Results: We found in the multivariate analysis
that women, lower extremity tumours
and radiotherapy had a significantly
negative effect on TESS score (OR =
3.76, 9.49 and 4.50, respectively).
However the predictors had no
significant effect on the MSTS score
and quality of life. There was a strong
correlation between functional
outcome and quality of life. Patients
who had physiotherapy had a lower
functional outcome compared to
patients who did not receive
physiotherapy, and there was no
difference found in quality of life.
Conclusions: Female sex, lower extremity tumours,
and radiotherapy were related to a low
TESS score and there was a strong
relation between functional outcome
and quality of life.
96. Influence of the Extent of Surgery on Patient Survival after Total Joint Replacement because of Metastatic Bone Disease
Michala Skovlund Sørensen, Kristine Grubbe Gregersen, Hindsø Klaus, Petersen Michael Mørk
Ortopædkirurgisk afdeling, Rigshospitalet
Background: In patients with a pathological fracture or
painful lesions because of metastatic
bone disease (MDB) in the extremities
various treatment modalities are
available ranging from conservative
treatment with radiation therapy over
minimal invasive osteosynthesis to
extensive bone resection and
reconstruction with tumour prosthesis.
Purpose / Aim of Study: To evaluate if extent of surgery
influence patient survival after total joint
replacement because of MBD.
Materials and Methods: We included a consecutive series of
patients (n=130, mean age 64(30-85)
years, F/M=76/54) that received a joint
replacement operation due to MBD
(metastases/haematological disease
=114/16) during the period January 2003
to December 2008. The cohort was
followed until marts 29th 2011 or until
death.
The following data were registered:
duration of operation, blood loss, bone
resection performed (yes/no), age,
gender, the American Society of
Anaesthesiologists (ASA) score, and
primary type of cancer (divided into 3
groups depending on median survival
found in the present study).
Statistics: Kaplan-Meier survival analysis
with log-rank test and Cox proportional
hazard regression analysis. P < 0.05
was considered statistical significant.
Findings / Results: The probability of patient survival was
51%, 39%, and, 29% after 6, 12 and 24
months respectively.
Duration of surgery (mean 164 min;
range 60 – 360 min), blood loss (mean
1273 ml; range 100 – 7000 ml), bone
resection (yes/no=102/28) did not
influence survival (p=0.83, p=0.39 and
p=0.76 respectively) while ASA-score
and cancer type was significant
predictors for survival (p<0.01 for both
variables).
Conclusions: Major surgery did not influence survival
in patients treated with joint replacement
surgery due to MBD. Survival was
determined by co-morbidity and cancer
type.
97. Local recurrence rate of Giant Cell Tumors of Bone
Peter Horstmann, Michael Mørk Petersen
Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
Background: Giant cell tumor (GCT) of bone is a
benign but locally aggressive tumor
and metastatic spread to the lungs is
possible.
Purpose / Aim of Study: To determine the local recurrence rate
of GCT of bone, the rate of lung
metastases and the rate of malignant
transformation.
Materials and Methods: Retrospective collection of data from
patients with GCT of bone treated in
our clinic from 1997 to 2012. Thirty-
four patients (mean age 34 (14-68)
years, F/M = 20/14) were included; 4
patients with GCT in the spine were
excluded because treatment routines
were significantly different to other
anatomical locations. A high
percentage (62%) of GCT’s was
localized in close relation to the knee
joint. Data were collected from patient
files and the Danish National
Pathology Registry (DNPR). Statistics:
Data are presented as mean (range).
Kaplan Meier Survival analysis.
Findings / Results: Intralesional curettage and bone
grafting was performed primarily in 32
patients (94%) and wide resection in 2
patients (6%). Mean follow-up was 81
(11-194) months. Thirteen patients
(38%) had local recurrence of GCT 16
(4-58) months postoperatively, and the
5-year recurrence free survival was
57%. Local recurrence was found in 1
case of wide excision. Five patients
who primarily were treated with
curettage were later treated with wide
excision. Four patients needed more
than one curettage after local
recurrence. Malignant transformation
where found in 1 case and that patient
later developed lung metastases. No
other lung metastases were found.
Conclusions: The choice of treating GCT’s with
curettage seems reasonable in spite of
a relatively high recurrence rate
because lung metastases and
malignant transformation is rare and
complications related to wide excisions
are avoided.
98. Adaptive bone remodeling of the femoral bone after tumor resection arthroplastry with an uncemented proximally hydroxyapatite coated GMRS stem.
Mikkel Rathsach Andersen, Michael Mørk Petersen
Department of Ortopaedics, Rigshospitalet; Derpartment of Ortopaedics, Rigshospitalet
Background: Loss of bone stock as a response to
bone trauma, postoperative
immobilisation and stress shielding often
leads to pronounced bone loss of the
affected bones after joint replacement
surgery.
Purpose / Aim of Study: The aim of the present study was to
investigate the adaptive bone
remodelling of the femoral bone after
implantation of a tumour prosthesis using
an uncemented press fit stem.
Materials and Methods: We performed 1 year follow up of 6
patients (mean age 54,6 (26-78) years,
F/M= 3/3) who underwent bone tumour
resection surgery of the femur.
Reconstruction were done using GMRS
(Stryker) tumour prostheses, with a 125
mm uncemented press-fit titanium alloy
stem, with hydroxyapatite (HA) coating
of the proximal part of the stem.
Measurements of bone mineral density
(BMD) were done postoperatively and
after 3, 6, and, 12 months. BMD was
measured in 3 regions of interest (ROI)
of the femur bone containing the GMRS.
Statistics: non-parametric analysis of
variance (Friedmann test) for evaluation
of changes in BMD over time. P-values
below 0.05 were considered significant.
Findings / Results: BMD decreased in all 3 ROI with time. In
ROI 1(p=0.01) BMD was already
decreased by 10% after 3 months and
ended with a total decrease of 14%
after 1 year. In ROI 2 (p=0.006) BMD
was decreased by 6% after 3 and 6
months; after 1 year of follow-up BMD
was 9% below the postoperative value.
In ROI 3 (p=0.009) BMD was decreased
by 6% after 3 and 6 months; after 1 year
of follow-up BMD was 8% below the
postoperative value.
Conclusions: A bone loss of 8-9% during the first
postoperative year was seen of the
bone along the femoral stem, but in the
bone close to the resection surface
containing the HA coated part of the
stem the decrease in BMD was 14%,
thus indicating that stress shielding of
this part of the bone may play a role for
the adaptive bone remodelling.
99. Through knee amputation associated with high risk of reamputation
Nikolaj Sode, Steen Vigh Buch, Troels Riis, Søren Kring, Annette Sylvest, Benn Duus
Department of Orthopedic Surgery, Bispebjerg Hospital
Background: Non-traumatic through knee amputation
(TKA) is used when below knee amputation
is not possible due to insufficient healing
potential, or in order to avoid contractures.
The patients are often frail and multimorbid.
Recent studies show reamputation rates of
6-20% for TKA and 3-48% for above knee
amputation (AKA).
Purpose / Aim of Study: The aim of this study is to review the
reamputation rates for primary TKA or AKA
and identify factors associated with risk of
reamputation.
Materials and Methods: Patients who underwent a primary TKA or
AKA at Bispebjerg Hospital, Copenhagen, in
the period from February 2009 to February
2013 were included.
154 patients (82 male, 72 female) with 69
TKA and 85 AKA were identified. Mean age
was 74.0 years (ST.D. ±11,3). P<0.05 was
considered significant.
Patient records, and blood results were
reviewed retrospectively.
Findings / Results: Reamputation rate within 90 days (R90)
of primary TKA were 34,8% with hazard
ratio 3,80 (1,55-9,32 95% C.I.) compared
to a R90 of 9,4% for primary AKA.
Each increase in ASA classification level
increased hazard ratio for R90 with 2,78
(1,34-5,79 95% C.I.) and a potassium
level above 4,3 mmol/L increased hazard
ratio for R90 with 3,30 (1,42-7,69 95%
C.I.). We found no significant difference
for sex, age, BMI, diabetes, prior
vascular reconstruction or history of
tobacco or alcohol use. For
bloodsamples we found no significant
difference for elevated levels of
creatinine, leucocytes, CRP or low levels
of hemoglobin or albumin.
Conclusions: In this study we found a high rate of
reamputation after primary TKA and a low
rate of reamputation for AKA, and therefore
we will evaluate our treatment strategy for
these patients. We found an increased risk
of reamputation with each increase in ASA
group, and with potassium levels within
normal physiological range and above.
100. Clinical outcome after treatment of paediatric elbow fracture; a comparison of supracondylar, lateral condyl and medial epicondyl fractures; is physiotherapy mandatory as adjuvant treatment?
Pernille Bovbjerg, Zaid Al-Aubaidi
Orthopeadic, Odense University Hospital
Background: Fractures involving the distal humerus
are very common in the paediatric
population. The most frequently of
those being: supracondylar (SC),
lateral condyle (LC) and medial
epicondyle fractures (ME).
Purpose / Aim of Study: To analyze the outcome after operative
treatment and see the impact of
adjuvant physiotherapy (Phys). We
expected to find the worse range of
motion (ROM) for ME because of the
elbow dislocation.
Materials and Methods: The cohort was found at a single
institution searching FPAS using ICD
and treatment code in the years 2000-
2010.We compared ROM registered in
the charts at the last post operative
follow up. ROM was divided into 5
groups; 1: normal, 2: having defect in
extension less than 10°, 3: having
defect in extension and flexion less
then 10°, 4: having extension or flexion
more than 10° and 5: unknown. We
chose to classify group 3 and 4 to be
bad ROM.
Findings / Results: In total 221 patients; 158 SC, 35 MC
and 28 LC. The mean age in years
was 11[5-15] for ME, 7 [4-14] for SC
and 7.8 [5-13] for LC. ROM was not
registered in the medical charts for
17.5% of those who received Phys and
for 23.9% who didn't. For ME there
was no positive impact on ROM in
patients who received phys, although
50% of the patients with elbow
dislocation were sent to phys. For LC
the ROM was worse for patients who
received phys. For SC we found a
better ROM for patients who did
receive adjuvant phys. 34.5% of
Gartland 3 were sent to phys while
only 20% of Gartland 1 and 2. There
was no difference in ROM between
Gartland 1, 2 and 3.
Conclusions: Although ROM for a big part was not
registered in the chart in our cohort, we
could not conclude that physiotherapy
has a positive impact on post-operative
ROM. Further research is needed to
illuminate the role of physiotherapy as
a mandatory part of treatment in elbow
fractures in the pediatric population.
101. Can the Ottawa Ankle Rules be applied in children with ankle injury? A prospective MRI study.
Mikael Hofsli, Trine Torfing, Zaid Al-Aubaidi
Department of Orthopedic Surgery, Odense University Hospital; Department of Radiology , Odense University Hospital
Background: Clinical evaluation of the paedaitric ankle
injuries can be challenging. The validation of
Ottawa Ankle Rules (OAR) for the paediatric
patients could help in the decision making,
whether radiographs should be obtained. To
the best of our knowledge, there are no
prospective studies utilizing magnetic
resonance imaging (MRI) to verify OAR in
children.
Purpose / Aim of Study: The aim of this study was to validate OAR in
children by the use of MRI.
Materials and Methods: 391 with acute ankle trauma, from
September 2012 to May 2013 at one
institution. 37 patients suspected of ankle
fracture were included and underwent an
initial clinical examination with OAR and
radiography. Patients were then referred for
an MRI within few days. All images were
reviewed and data were recorded
prospectively. All patients were seen for a
clinical follow-up and informed about the MRI
results. The clinical data and the initial
radiographs were blinded to the senior
radiologist, whom interpreted the MRI.
Findings / Results: 37 (100%) met the criteria to obtain
radiographs by OAR. 3 patients (8%) were
excluded due to dropout and 3 (8%) had a
fracture on the initial radiography. This
resulted in a total of 31 patients referred to
MRI without a fracture on initial radiography,
18 males and 13 females, mean age
10±2.86. The time between the injury and
the initial radiological examination was
0.4±0.88 days and the MRI was obtained on
an average of 6.9±2.87 days.1 patient
(3.2%) had a bony flake fracture of the
lateral malleolus verified on the MRI, making
a total of 4 patients (10.8%) with fractures.
Conclusions: In this study OAR recommended
radiographical evaluation of all patients.
However, only 3 had fractures verified on
initial x-ray and 1 on subsequent MRI,
According to this study, OAR is not
recommended for clinical evaluation in
children, due to a high false-positive rate.
102. The proportion of distal fibula Salter Harris type I epiphyseal fracture in the pediatric population with acute ankle injury. A prospective MRI study.
Mikael Hofsli, Trine Torfing, Zaid Al-Aubaidi
Department of Orthopedic Surgery, Odense University Hospital; Department of Radiology , Odense University Hospital
Background: Ankle injuries are common among the
pediatric population and may result in
fractures, ligaments or osteochondral injury.
There are few prospective studies utilizing
magnetic resonance imaging (MRI) to
diagnose a clinically suspected Salter-Harris
type 1 of the distal fibula (SH1DF).
Purpose / Aim of Study: The aim of this study was to examine the
proportion of clinically suspected SH1DF in
children.
Materials and Methods: 391 patients with ankle injury, seen at the
emergency room (ER) from September
2012 to May 2013 at single institution. All
underwent a standardized clinical
examination and radiographs was obtained if
found necessary. Initial radiographs were
reviewed by an orthopedic specialist and a
radiologist specialist and data was recorded
prospectively. Patients suspected of having
SH1DF were referred for an MRI of the
ankle joint within few days. All patients were
seen for a clinical follow-up and informed
about the MRI results. The clinical data and
the initial radiographs were blinded to the
senior radiologist, whom interpreted the MRI.
Findings / Results: 38 patients had a clinical suspicion of
SH1DF. 7 patients were excluded from the
study. 3 were excluded, as there was
fracture on the initial radiography. One due
to closed physis and 3 due to drop out. A
total of 31 patients, 18 male and 13 female,
mean age 10±2.86. The time between the
injury and the initial radiological examination
was 0.4±0.88 days. MRI was obtained on an
average of 6.9±2.87 days. None of the
included patients had evidence of SH1DF on
MRI imaging.
Conclusions: According to this study, the clinical diagnosis
of SH1DF was incorrect in all of the cases.
This study and review of the literature
verifies the high false-positive rate of
clinically suspected SH1DF. These results
may influence the management of clinically
suspected SH1DF.
103. Pitfalls in the treatment of pediatric supracondylar fractures of the humerus – a partial root core analysis of 101 cases from the Danish Patient Insurance
Folkvardsen Steffen , Baslev-Clausen Andreas , Krogh Christoffersen Jens , Sonne Holm Stig , Wong Christian
Department of Orthopaedic Surgery , University Hospital of Hvidovre; , The Patient Insurance Association; Department of Pediatric Orthopaedic Surgery , University Hospital of Hvidovre
Background: The supracondylar fracture of the
humerus is the most common fracture
in the pediatric elbow. Danish Patient
Insurance Association (DPIA) receives
complaints from patients who believe
they have sustained injuries due to
potential malpractice or unfortunate
circumstances.
Purpose / Aim of Study: Case files from DPIA were assessed to
identify causality and factors
contributing to complaints and potential
malpractices of supracondylar
fractures in children.
Materials and Methods: A partial root core analysis was
performed of a total of 101 cases.
Case files for supracondylar fractures
were retrieved from the DPIA database
for the diagnose codes DS 42.4 and
DS 42.4C for patients under the age of
16.
Findings / Results: The boy:girl ratio was 3:2 and with an
average age of 6,7 years. According to
the Gartland classification: Six were
classified as type 1, 49 as type 2, 41
as type 3 and five cases of flexion type
fractures.
The main complaints were related to
malpractice (47), poor functional
outcome (45), cubitus varus (38) and
neurological symptoms (18). 38 of the
cases were operated on by a specialist
in orthopaedics. 32 were treated
conservatively with cast including 9
cases supplemented by closed
reduction. 69 were operated by either
closed (19) or open (50) reduction
supplemented by k-wire fixation.
The rate of complications increased
with fracture severity by the Gartland
classification and almost all flexion
type fractures had reoperations. Half of
the injuries were evaluated as minor
injury by the DPIA, but a total number
of 48 cases were acknowledged.
Conclusions: Malpractice in surgical technique
seemed to be overrepresented in the
severe fractures even when operated
on by an orthopaedic specialist. In
order to optimize treatment, operating
doctors would need to be especially
trained to deal with these kinds of
fractures when severe.
104. Outcome of distal tibial physeal fractures; a comparison of Triplane, Tillaux and medial malleolus SH-III and IV fractures. A retrospective study.
Helene Højsgaard Jensen, Sidsel Hald Rahlf, Niels Wicbech Pedersen, Zaid Al-Aubaidi
Ortopædkirurgisk Afdeling, Odense Universitetshospital (OUH)
Background: Ankle fractures occur frequently in
adolescent patients. Fractures that
involve the physis can result in Tillaux
(TI), Triplane (TR) or medial malleolus
fracture (MM). Those can result in
growth arrest, which can lead to
deformity and shortening of the distal
tibia. We expected that medial
malleolus fractures have the highest
risk of developing growth arrest, as it
occurs in a younger age group, with
more growth potential.
Purpose / Aim of Study: To examine the outcome and
distribution of growth arrest after the
physeal fractures of the distal tibia.
Materials and Methods: A retrospective study where the study
population was identified through
analysis of medical records and x-rays
of all adolescent patient with a distal
tibia fracture registered at a single
institution in the period from 2003 –
2012.
Findings / Results: 51 patients, 53% female and 47%
male. 71% of the fractures were
located to the right ankle (n=36). There
were 15 TR, 9 TI and 27 MM fractures.
The mechanisms of injury were: sprain
(56.9%), fall from height (15.7%),
motor vehicle accident (11.8%) and
undefined (15.6%).
The mean age was: 13.5 TR (10-16),
13.2 TI (12-15) and 12.9 years MM (8-
16). There were no significant
statistical differences between the 3
groups regarding incidence of growth
arrest: MM vs. TR p=0,47 (NS), MM
vs. TI p=0,56 (NS) and TR vs. TI = NA.
Conclusions: This study shows a trend towards
higher risk of developing growth arrest
when suffering from a MM compared to
the other transitional fractures.
However this clinical trend should be
interpreted with the scope of this study
and further research is necessary to
illuminate this aspect of physeal
fractures and their complications.