Session 13: Foot/ankle
Fredag den 25. oktober
11:00 – 12:00
lokale: Helsinki/Oslo
Chairmen: Jeannette Østergaard Penny / Lasse Danborg
124. Dynamic non-operative treatment of acute Achilles tendon rupture: The influence of early weight-bearing on clinical outcome. A blinded, randomized, controlled trial.
Kristoffer W Barfod, Jesper Bencke, Hanne Bloch Lauridsen, Ilija Ban, Lars Ebskov, Anders Troelsen
Orthopaedic surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark; Gait Analysis Lab, dep. of Ortopaedic surgery, Copenhagen University Hospital, Hvidovre, Denmark; Orthopaedic surgery, Copenhagen University Hospital, Hvidovre, Denmark; Ortopaedic surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
Background: Weight-bearing (WB) during rehabilitation of
acute Achilles tendon rupture (ATR) has
positive impact on the health related quality
of life, and it might allow for quicker return to
work. WB after surgical repair of ATR has
shown no detrimental effects, but there are
no clinical studies examining the role of WB
in non-operative, dynamic treatment of ATR.
Purpose / Aim of Study: To compare the functional outcome of
patients randomized to early WB or non-WB
in non-operative, dynamic treatment of ATR.
Materials and Methods: The study was conducted as a blinded,
randomized controlled trial (RCT). 60 patients
were randomized. 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.
Outcome at 6 and 12 months was evaluated
using the Achilles tendon Total Rupture
Score (ATRS), the Heel-rise-work-test and
the rerupture rate (RR). Data were
evaluated using unpaired T-tests.
Findings / Results: There were no statistically significant
differences between the WB and the non-
WB groups. Mean ATRS at six months was
59 for the WB group and 67 for the non-WB
group (p=0.16). At 12 months the ATRS was
73 WB and 75 non-WB (p=0.72). The Heel-
rise-work-test showed a total work
performed of the injured limb compared to
the uninjured limb of 40% for the WB group
and 37% for the non-WB group at six month
(p=0.58). At 12 months it was 53% WB and
57% non-WB (p=0.52). There were 3 RR in
the WB group and 2 RR in the non-WB.
Conclusions: There were no significant differences
between the groups in ATRS or Heel-rise-
work-test at one-year follow-up. Both
groups had significant functional deficits in
the injured limb compared with the uninjured
limb. Immediate weight-bearing is a
recommendable option in the non-operative
treatment of ATR.
125. High volume injection, autologous conditioned plasma and placebo treatment in patients with chronic Achilles tendinopathy– A single blinded prospective study
Anders Ploug Boesen, Morten Boesen, Rudi Hansen, Peter Malliaras , Otto Chan, Henning Langberg
Department Ortopaedic Surgery, Institute of Sports Medicine Copenhagen, Bispebjerg Hospital, Denmark; , Teres Parkens Privat Hospital, Denmark; Department of Public Health, Faculty of Health Sciences University of Copenhagen, CopenRehab, Section of Social Medicine
Background: Chronic Achilles tendinopathy (AT) is a
commen and impairing disorder. Only
sparse scientific evidence exists for the
present used treatments and no golden
standard treatment exists.
Purpose / Aim of Study: The aim of the study was in AT patients to
examine and compare the effect of high
volume injection (HVI) or autologous
conditioned plasma (ACP) in combination
with eccentric training to placebo (Plc)
treatment (sham treatment and eccentric
exercises).
Materials and Methods: Healthy males (21-59 years; n=55) with AT
were randomly assigned to HVI (10 mls
0.5% Marcain and 20 mg Depomedrol
followed by 40 mls saline), ACP (4 mls) or
Plc (sham) treatment. Participants were
treated 4 times with 2 wk interval (HVI only
once a baseline). All underwent a 12-wk
eccentric training program. Outcome
measures were assessed at 12 and 24 wk
follow-up by VISA-A and VAS score,
ultrasound thickness and muscle function
(heel-rise test).
Findings / Results: Increase in VISA-A was seen in all follow-
ups for every group (p<0.05). The
increase was higher in HVI vs ACP and
Plc at 12-wks follow-up (p<0.01), with no
difference between ACP vs Plc. At 24
wks follow-up a higher increase was
found in the HVI and ACP vs Plc
(p<0.05). VAS score decreased in all
follow-ups for every group (p<0.05). The
decrease was higher in HVI and ACP vs
Plc at 12-wks follow-up (p<0.05) , with no
differences between HVI and ACP. At 24
wks follow-up a higher decrease was
found in HVI and ACP vs Plc (p<0.05).
Tendon thickness showed a significant
decrease in HVI and ACP in all follow-
ups. The decrease in thickness at 12
wks follow-up was greater in HVI vs ACP
(p<0.01), and ACP vs Plc (p<0.05). At 24
wks follow-up a higher decrease was
found in HVI and ACP vs Plc with no
differences between HVI and ACP.
Muscle function improved in the entire
cohort (p<0.01) with no group interaction
observed.
Conclusions: Treatment with HVI or ACP in combination
with a 12-wk eccentric training regime in AT
seems more effective reducing pain,
improving activity level and reducing tendon
thickness than eccentric training, per se.
HVI was found more effective than ACP in
this short-term study.
126. Modified Lapidus arthrodesis – Plantar plating and compression screw Retrospective evaluation of fusion rate and IM-1 angle correction
Kim Hegnet Andersen, Anna Kathrine Pramming, Jens Kurt Johansen, Jeannette Østergaard Penny
Foot and Ankle department, Koege Hospital
Background: The Lapidus procedure for treating
metatarsus primus varus or instability
of the TMT-1 joint is well established.
Nonunion rates of 4-25% are reported.
Crossed screws or medial or dorsal
plating in addition to a compression
screw are standard techniques.
A plantar plate adds the advantage of
tension band effect over the fusion site
which has been shown in a
biomechanical study.
Purpose / Aim of Study: To report fusion- and complication
rates for the Lapidus procedure with
plantar plating, and secondly the
correction of the IM-1 angle in
metarsus primus varus.
Materials and Methods: All patients operated at our department
using the Darco LPS plate were
evaluated (n=41).
Indications were: Metatarsus primus
varus(33pts), revision hallux valgus
surgery, instability of TMT-1 in midfoot
dysfunction/forefoot driven hindfoot
valgus and/or arthritis of the TMT-1
joint.
All patients were evaluated clinically
and radiographically 3-4 and 6-8
weeks postoperatively.
The post-op regime was full/partial
weightbearing in a post-op shoe.
IM1-angle measured pre- and
postoperatively, independently by first
3 authors.
Means compared by a paired t- test,
and agreement by interclass
correlation coefficient(ICC).
Findings / Results: All patients fused both clinically and
radiographically.
IM-1 angle reduced from 16, 5 to 7, 8
degrees (pre/postoperative) (p <
0.0001).
Pre ICC (95%CI) = 0.83 (0.74-0.92)
and post ICC (95%CI) = 0.85 (0.77-
0.93).
6 patients had minor complications,
including 2 screw removals due to
malpositioning. 1 patient had
(traumatic) rupture of tibialis anterior
tendon.
Conclusions: The use of the Darco LPS plate yields
good short term results with high
fusion rate and low rate of
complications. When indicated the IM-
1 angle was corrected significantly and
the angle measurements were valid.
Long term follow-up as well as
prospective studies are needed.
127. Surgical treatment of lesser-toe- MTP joint instability: Plantar plate repair using a plantar approach.
Anna Kathrine Pramming, Jens Kurt Johansen, Kim Hegnet Andersen, Jeanette Østergaard Penny
Foot and Ankle Department, Koege Hospital
Background: The plantar plate (PP) is the principle
stabilizing structure of the lesser toe-
MTPJ. There is to this point no golden
standard treatment for the instable
lesser MTPJ. Few clinical studies have
been published, some recommending a
dorsal approach through a Weil
osteotomy. This however changes the
center of rotation, and cadaver studies
find that anatomical repair
reestablishes stability and alignment.
The plantar approach allows direct
anatomical repair, but has been avoided
by many due to fear of painful scarring.
Purpose / Aim of Study: To evaluate the use of a plantar
approach in surgical repair of the
plantar plate.
Materials and Methods: All patients at our institution (n=19),
treated with PP repair only or combined
with additional procedures, were
examined at a median 24 weeks (8 to 50)
postoperatively using the AOFAS
forefoot-scale, VAS-FA and a
standardized clinical evaluation.
8 were revision cases.
The PP rupture was debrided and sutured
or reinserted using anchor fixation to
the base of the proximal phalanx.
Findings / Results: All plantar incisions healed with
minimal scarring. Post operative VAS-FA
scored a mean 77.9 (sd 15.8) points and
AOFAS forefoot scored a mean 77.5 (sd
15) points. Compared to the opposite
side dorsiflexion was reduced by 17°
(p<0.01).
3 patients were failures
(malalignment/elevation) at follow-up.
One was a rheumatoid patient and two did
not present a typical plantar plate
rupture at surgery, but rotation of the
joint capsule and luxation of the flexor
tendon complex.
2 reported tenderness at the plantar
incision,
4 had pain or tenderness at the dorsal
incision.
Conclusions: Surgical repair using a plantar approach
yields good results regarding
realignment and foot function. The
failure risk regarding rheumatic
arthritis needs further investigation.
Plantar scar complications do not seem
to be significant.
128. Development and validation of a novel ultrasonographic method for evaluation of Achilles tendon elongation after rupture
Kristoffer W Barfod, Anja Falck Riecke, Anders Boesen, Philip Hansen, Jens Friedrich Maier, Anders Troelsen
Orthopedic surgery, Copenhagen University Hospital, Køge, Denmark; Institute of Sports Medicine, Copenhagen University Hospital, Bispebjerg, Denmark; Radiology, Copenhagen University Hospital, Bispebjerg, Denmark; Ortopaedic surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
Background: Elongation of the Achilles tendon after acute
rupture is associated with inferior functional
outcome. A clinically applicable, accurate
and easy to perform method for evaluating
Achilles tendon elongation is needed.
Purpose / Aim of Study: To develop and validate an ultrasonographic
(US) method that accurately measures the
length of the Achilles tendon-aponeurosis
complex.
Materials and Methods: Both legs of 19 non-injured subjects
were examined by MRI and US. The
length of the Achilles tendon-
aponeurosis complex (calcaneus to the
medial head of m. gastrocnemius) was
measured by three independent US
examiners. Repeated US measurements
were performed and compared to MRI
measurements. Intra-rater and inter-rater
reliability was determined and the
agreement between MRI and US was
determined. Data were evaluated using
the Bland-Altman method and the Inter
Correlation Coefficient (ICC), the
Standard Error of the Measurement
(SEM) and the Minimal Detectable Change
(MDC).
Findings / Results: Intra-rater reliability showed no significant
systematic differences between test days
(p=0.45); ICC 0.96, SEM 3.7mm and MDC
10.3mm. Inter-rater reliability showed a
systematic difference between US
observers of 2.1mm – 4.5mm (p=0.001-
0.036); ICC 0.97, SEM 3.3mm and MDC
9.3mm. MRI measurements were on average
3.8mm longer than US (p=0.001); ICC 0.98,
SEM 2.7mm and MDC 7.6mm. We found no
systematic difference in length of the left
and the right Achilles tendon (p=0.95); ICC
0.94, SEM 4.1mm and MDC 11.5mm.
Conclusions: The novel US method showed good
reliability. For comparison between groups
of non-injured subjects differences of more
than 4mm can be detected. For repeated
assessment of individual subjects
differences of more than 10mm can be
detected. The novel US method is a
promising clinical tool to be further assessed
in the setting of acute Achilles tendon
rupture.
129. Achilles Tendon ruptures – treatment and complications: A systematic review
Christina Holm, Pernilla Eliasson
Idrætsmedicinsk Institut, Bispebjerg Hospital
Background: Achilles tendon rupture is a frequent sports
injury with increasing incidence. Until now
there is no consensus regarding the optimal
treatment for acute Achilles tendon ruptures.
Purpose / Aim of Study: The purpose of this study was to illuminate
and summarize randomized controlled trials
comparing surgical and non-surgical
treatment of Achilles tendon ruptures.
Materials and Methods: We systematically searched MEDLINE
database for randomized prospective
controlled trials on humans, comparing
surgical and non-surgical treatment of
Achilles tendon rupture, for the last 10
years. Six articles were found acceptable
according to international quality
assessment guidelines. Primary outcomes
were re-ruptures, complications of
treatment, and functional outcomes.
Findings / Results: All studies used early mobilization in both
groups. There was no significant difference
in re-rupture rate, but a trend favoring
surgery patients. No significant differences
in other types of complications, was found,
although one study found a increased risk
for soft-tissue related complications in the
surgery group, that did not affect functional
outcome. Patient satisfaction and time to
return to work were significant different in
favor of surgery in one study and there
were better functional outcomes for surgery
patients, at early time-points.
Conclusions: We found no significant differences in re-
rupture rate although a trend favoring
surgery. Surgical patients had significant
better early functional outcomes and also
returned to work earlier, indicating that
their rehabilitation is faster combined with
early mobilization.
Further randomized controlled trials will
be needed in regards to understand the
interplay between acute surgical or non-
surgical treatment and the rehabilitation
regimen for the overall outcome of
Achilles tendon treatment.
130. Complications after acute Achilles tendon rupture. A registry study of 324 patients from the Danish Patient Insurance Association
Thor-Magnus Sveen , Kristoffer W. Barfod , Lars Ebskov, Anders Troelsen
Orthopaedic surgery, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark; Orthopaedic surgery, Copenhagen University Hospital, Hvidovre, Denmark
Background: The best treatment of acute Achilles tendon
rupture (ATR) has been discussed for
decades. High quality meta-analysis
comparing surgical and non-surgical
treatment show a lower re-rupture rate but
a higher overall complication rate among
surgically treated patients. There are no
studies evaluating the impact of different
complications.
Purpose / Aim of Study: To investigate: 1) the number and types of
complications reported to the Danish Patient
Insurance Association (DPIA) after treatment
for ATR, and 2) if complications are
correlated to the treatment given.
Materials and Methods: This registry study examined the DPIA
database. 324 patients with ATR reported in
the period 1992 to 2010 were identified. All
patient records were reviewed and data
were assessed to confirm correct
registration of diagnosis and complications.
Findings / Results: Awarded compensation for the 12 year
period totaled 18,147,202Dkk. Out of 180
operatively treated patients, 79 received a
total compensation of 14,051,377Dkk,
averaging 177,865Dkk per patient. Of 114
non-operatively treated patients, 39 received
a compensation of 3,715,224Dkk, averaging
95,262Dkk per patient. In the group of
operatively treated patients there were 48
infections, 23 nerve damages, 23 re-
ruptures, 9 deep venous thrombosis and 6
tendon elongations. Among the non-
operatively treated patients there were 24
re-ruptures and 21 tendon elongations.
Conclusions: Approximately 10 cases of ATR were
accepted for compensation in the DPIA per
year; 1/3 after non-operative treatment and
2/3 after operative treatment. The average
compensation after operative treatment was
twice that after non-operative treatment
indicating more severe complications after
operative treatment.
131. Prospective comparative study comparing the results of proximal crescentic osteotomies and open wedge osteotomies to patients with severe hallux valgus
Jens Ulrik Wester, Niels Herold, Palle Bo Hansen, Johnny Frøkjær
Orthopedic, Odense University Hosptial
Background: Different techniques of proximal
osteotomies have been introduced in
correcting severe hallux valgus. The
open wedge osteotomi is a newly
introduced method for proximal
osteotomi .
Purpose / Aim of Study: The aim of this prospective randomised
study was to compare the radiological
and clinical results 4 and 12 months
after the operation to patients with
severe hallux valgus, comparing the
open wedge osteotomi to the
crescentric osteotomi.
Materials and Methods: 45 patients with severe hallux valgus
HV-angle >35, and IM angle > 15 were
included in this study. The treatment
was proximal open wedge osteotomi
and fixation with plate (Hemax) group 1,
or operation with proximal crescentic
osteotomi and fixation with 3 mm
canulated screw (Synthes) group 2.
Clinical and radiological follow-up was
performed 4 and 12 months after the
operation.
Findings / Results: The Aofas score was improved form
59,3 to 81,5 group 1, in group 2 the
improvement increased from 61,7 to 84,8
after 12 months. In group 1 the hallux
valgus ankle decreased from 39,1 to
23,1 after 4 months and 26,6 after 12
months. In group 2 the angle
preoperative was 39,1, 22,5 after 4
months and 27,2 after 12 months. The
intermetatarsal angle in group 1 was
19,0 before operation, 11,6 after 4
months and 12,5 after 12 months. In
group 2 the mean intermetatarsal angle
was 18,9 preoperatively, 12 after 4
months and 12,6 after 12 months. The
length of the 1. metatarsal compared to
2. metatarsal bone was 0,884
preoperatively and 0,875 postoperatively
in group 1. In group 2 0,872
preoperatively and 0,88 after 12
months.
Conclusions: : In both groups the hallux valgus angle
had a tendency to recur in time after
the operation, no statistical difference
were found in the study. There was a
tendency to gain length of the first
metatarsal using the open wedge
osteotomi compared to the crescentic
osteotomi. If the patient has a tendency
to instability or if the TMT joint is big one
should consider Lapidus procedure as
the primary operation procedure.