Postersession III

Onsdag den 22. oktober
11:00 – 12:00
Lokale: Helsinki/Oslo
Chairmen: Jeannette Ø. Penny / Anders Troelsen

165. Does an intensive alcohol cessation intervention at the time of fracture surgery induce spontaneous smoking cessation? - The Scand-Ankle study
Erika Wernheden, Marianne Aalykke, Bolette Pedersen, Julie W. M. Egholm, Hanne Tønnesen
WHO-CC, Frederiksberg Hospital; Clinical Health Promotion Centre, Lund University; Syddansk Universitet, Sygehus Sønderjylland

Background: Patients with high alcohol consumption are at greater risk of developing postoperative complications than patients with low/no alcohol consumption. Other risk factors are smoking, overweight, malnutrition and physical inactivity. Preoperative alcohol and smoking cessation programs have been found effective in reducing postoperative morbidity, but it remains unknown whether these induce a general change of lifestyle.
Purpose / Aim of Study: The aim of this study was to find out whether the gold standard alcohol intervention programme (GSP-A) used in the Scand-Ankle study, affected smoking, overweight, malnutrition and physical inactivity.
Materials and Methods: 64 patients with high alcohol consumption, who underwent ankle fracture surgery, were randomized to the GSP-A or usual care (control). The two groups were compared at baseline and 6 weeks follow- up regarding changes in lifestyle factors. Data were analyzed on an intention to treat (ITT) basis using non-parametric statistics. A per protocol analysis of whether alcohol cessation, regardless of study group, affected lifestyle risk factors after 6 weeks was also performed.
Findings / Results: The ITT-analysis showed no significant differences between the GSP-A and control group regarding lifestyle risk factors other than alcohol. The per protocol analysis showed that alcohol cessation regardless of study group did not influence the other lifestyle risk factors.
Conclusions: The GSP-A, which has been proven effective on short-term alcohol cessation, does not affect smoking, overweight, malnutrition and physical inactivity. Thus, a potential effect of the GSP-A on postoperative complications will likely be due to the effect on alcohol intake and not to a general change in lifestyle. The findings suggest that multiple lifestyle interventions are required, e.g. combined alcohol and smoking cessation.

166. Compression in Anklefracture Treatment, the CAT-study
Rikke Winge, Stig Sonne-Holm, Camilla Ryge , Hans Gottlieb, Lasse Bayer
Orthopedic Surgery, Nordsjællands Hospital

Background: Malleolar fractures in Denmark has an incidence of 107/100.000 person, making it one of the most common fracture types in the country. In Denmark 6000 malleolar fractures are operated each year. Studies have shown increased complication rates in the elderly, diabetics, smokers, patients on immunomodulating medication, alcoholics, and patients with osteoporosis and peripheral neuropathy. Nordsjællands Hospital has decided, to implement a standard regime of elevation, Flowtron Hydroven 3™ and Coban™ 2 lite, to prevent oedema formation and blistering. The decision came after clinicians having observed a high incidence of oedema, blistering and wound healing problems in this cohort of patients, often forcing surgeons to postpone surgery and prolonging inpatient stay, resulting in a long and cumbersome rehabilitation for the patient.
Purpose / Aim of Study: To perform a randomized, controlled cohort study, to evaluate the effect of Flowtron Hydroven3™ and Coban2 lite™ on the incidence of complications (infection, wound dehiscence, prolonged healing, skin necrosis, exposed hardware, DVT, amputation and death) after operation for mono-, bi- and trimalleolar fractures at Nordsjællands Hospital.
Materials and Methods: 156 Patients with an unstable malleolar fracture, included and randomized in the ED. Intervention: Compression therapy in the form of Flowtron Hydroven3™ and Coban2 lite™compression bandage. Controle: Elevation of the ankle on a Braun frame. Follow-up: 6 weeks. The project manager will note any wound healing problems (infection, wound dehiscence, skin necrosis, visible osteosynthesis material).
Findings / Results: By the time of the DOS-congress, the authors are ready to present the preliminary data, concerning the first 78 patients (50% of expected)
Conclusions: Awaiting analysis of preliminary data.

167. Characteristics of non-participants in orthopaedic research – A study of patients undergoing ankle fracture surgery and declining participation in a randomized clinical trial
Marianne Aalykke, Erika Wernheden, Bolette Pedersen , Julie Weber Melchior Egholm, Hanne Tønnesen
WHOCC, Clinical Health Promotion Centre, Frederiksberg Hospital; WHOCC, Clinical Health Promotion Centre and Clinical Alcohol Research, Frederiksberg Hospital and Lund University ; WHOCC, Clinical Health Promotion Centre and Orthopedic Surgery, Frederiksberg Hospital and Sygehus Søndejylland ; WHOCC, Clinical Health Promtion Centre and Clinical Alcohol Research, Frederiksberg Hospital and Lund University

Background: Clinical experience indicates that patients declining participation in randomized clinical trials (RCTs) are older, less healthy and of lower social status than participants, bringing the non-participants in a higher risk at surgery. Results from studies investigating non-participants of RCTs in surgical settings are conflicting, and to our knowledge none of these studies exist on patients with risky drinking, who are already at high risk at surgery.
Purpose / Aim of Study: The aim of this study was to investigate characteristics and outcomes of patients undergoing ankle fracture surgery with risky drinking declining participation in the Scand-Ankle RCT.
Materials and Methods: The Scand-Ankle study is an on-going RCT, that investigates the effect of a 6- week gold standard alcohol intervention (GSP-A) on postoperative complications in patients drinking >21 units/week and undergoing ankle fracture surgery. This retrospective study included eligible patients that declined to participate in the Scand-Ankle RCT, but gave informed consent to follow-up in their medical record (N=67). Their perioperative patient characteristics and 6-week complication rate were obtained from their medical record material and the characteristics were compared to the patients enrolled in the study so far (N=61).
Findings / Results: The analyses on patient characteristics are on-going. 34% of the non-participants had complications, and the most frequent complication was wound infections.
Conclusions: A complication rate at 34% indicates that patients drinking > 21 units/week are at high risk at ankle fracture surgery, and the analyses on patient characteristics will show if the non-participants are at even greater risk.

168. Early Complications of Ankle Fractures Following Treatment with Ilizarov External Fixator or Open Reduction Internal Fixation
Josefin Roslund , Matilda Svenning, Michael Brix, Morten Schultz Larsen
Orthopaedic Surgery, Odense University Hospital

Background: Objective: Open reduction and internal fixation (ORIF) is the standard surgical treatment for ankle fractures in Denmark. In cases of compromised soft tissue, the Ilizarov external fixator (IEF), might be a safer alternative when fixation is needed.
Purpose / Aim of Study: The aim of this study is to analyse the short term complications following treatment of ankle fractures using IEF or ORIF.
Materials and Methods: Method: The study population consisted of 122 consecutive patients who were surgically treated for ankle fractures at Odense University Hospital (OUH) during the time period 01.05.2012 – 31.04.2013. Patients were divided into groups based on surgical treatment method (IEF or ORIF). Pre- defined outcomes, predisposing factors and other variables of interest were registered from medical records and x-rays.
Findings / Results: Results: 23 patients received IEF treatment and 99 received ORIF. Among the predisposing factors the variable “hypertension and/or hyperlipidemia” varied significantly, occurring more often in the IEF group, whereas the rest of the predisposing factors did not. Among the defined postoperative outcomes secondary loss of reduction showed a significant higher rate in the IEF group. Infection and reoperation did not differ significantly between the groups. No case of compartment syndrome or amputation occurred in any of the groups.
Conclusions: Conclusion: Even though the patients in the IEF group were generally considered to be in poorer condition prior to operation (higher age and rate of predisposing factors), the only outcome that was significantly different was secondary loss of reduction. This is consistent with the theory that IEF might be a good alternative for patients with less desirable preoperative conditions.

174. Knee Joint Loading Indices Before and 3 Months after Arthroscopic Partial Medial Meniscectomy
Jonas B. Thorlund, Mark W. Creaby, Martin Englund, Nis Nissen, L. Stefan Lohmander, Anders Holsgaard-Larsen
Department of Sports Science and Clinical Biomechanics, University of Southern Denmark; , Australian Catholic University, Brisbane, Australia; Department of Orthopedics, Lillebaelt Hospital, Kolding; Department of Clinical Science and Department of Orthopedics and Traumatology, University of Southern Denmark and Odense University Hospital

Background: Increased knee adduction moment (KAM) is considered an important biomechanical marker of medial compartment loading in knee osteoarthritis (OA) research. Patients undergoing arthroscopic partial medial meniscectomy (APMM) are at increased risk of developing medial compartment knee OA. APMM may contribute to altered knee joint loading patterns. However, this is currently unknown.
Purpose / Aim of Study: The aim of this study was to determine the short-term changes in knee joint loading indices from before to after medial APMM.
Materials and Methods: We investigated indices of knee joint loading (peak KAM and KAM impulse) using 3D gait analysis in 23 middle-aged patients (17 men, 46.3 yrs (SD 6.4), BMI 25.8 kg/m2 (3.4) before and 3 months after APMM for a degenerative tear. Patients had no radiographic knee OA (i.e. Kellgren & Lawrence grade 0 or 1) in the leg undergoing APMM or in their uninjured control leg prior to surgery. Data were collected during barefoot gait at self-selected walking speed (± 5% at follow-up). Paired t-tests were used to test for differences at baseline and differences in change over time between operated and control legs.
Findings / Results: No differences were observed between the operated and uninjured control leg in peak KAM (p=0.42) or KAM impulse (p=0.14) before APMM. No difference in change from before to 3 months after APMM were observed between operated and uninjured control legs in peak KAM (0.17 [95% CI, -0.13-0.49] Nm/BW*HT%), whereas a border line significant increase was observed in the APMM leg in KAM impulse (0.09 [95% CI, -0.01-0.19] Nms/BW*HT%).
Conclusions: Knee joint loading indices - as indicated by the KAM - do not appear to substantially increase in the operated leg compared with the uninjured control leg from before to 3 months after APMM in middle-aged patients with degenerative meniscal tears.

177. Outcome and risk of revision after shoulder replacement in patients with osteoarthritis: 1,209 cases from the Danish Shoulder Arthroplasty Registry
Rasmussen Jeppe, Anne Polk, Anne Kathrine Belling Sørensen, Bo Sanderhoff Olsen, Stig Brorson
Orthopaedic Surgery, Herlev Hospital

Background: Hemiarthroplasty (HA) including resurfacing hemiarthroplasty (RHA) and stemmed hemiarthroplasty (SHA)are widely used in Denmark but the efficacy in comparison to that of total shoulder replacement (TSA) is poorly documented.
Purpose / Aim of Study: In this study we used patient reported outcome and risk of revision to compare HA and TSA in patients diagnosed with osteoarthritis and secondly to compare SHA and RHA.
Materials and Methods: We included all patients reported to the Danish Shoulder arthroplasty registry (DSR) between January 2006 and December 2010. 1209 arthroplasties in 1109 patients were eligible. Western Ontario Osteoarthritis of the Shoulder index (WOOS) was used to evaluate patient reported outcome 1 year postoperatively. For simplicity of presentation, the raw scores were converted to a percentage of a maximum score. Revision rates were calculated by checking reported revisions to DSR until December 2011. WOOS and risk of revision were adjusted for age, gender, previous surgery and type of osteoarthritis.
Findings / Results: There were 113 TSA and 1096 HA (837 RHA and 259 SHA). Patients treated with TSA had a statistically better WOOS, exceeding the predefined minimal clinically important difference, at one year (mean difference 10, P<0.001). RHA had a statistically significant better WOOS compared to SHA (mean difference 5, P=0.024) but the difference did not exceed the minimal clinically important difference. There were no statistically significant differences in revision rate or adjusted risk of revision between any groups.
Conclusions: Our results are in accordance with the results from other national shoulder registries and the results published in systematic reviews favoring TSA in the treatment of osteoarthritis.

181. Biomechanical symmetry of a hip joint altered by Perthes’ disease
Remel Salmingo, Tina Skytte, Marie Sand Traberg, Kaj-Åge Henneberg , Klaus Hindsø, Christian Wong
Biomedical Engineering, Department of Electrical Engineering, Technical University of Denmark; Department of Orthopaedics, Hvidovre Hosptial

Background: Perthes is a disease characterized by a loss of blood supply of the hip joint resulting to malformation of the femoral head. Until now, the underlying biomechanical changes of Perthes’ disease need to be further elucidated.
Purpose / Aim of Study: The objective of this study was to investigate the changes specifically the biomechanical symmetry of a unilateral Perthes’ hip.
Materials and Methods: Finite Element (FE) modeling was performed to investigate the biomechanics of a healthy and diseased hip of a unilateral Perthes’ case. The image MRI slices were obtained to segment the bones and cartilages, and to build the 3D models. The elastic modulus for the pelvis, femur, cartilages and necrotic bone (Perthes’ hip only) were, 5 GPa, 500 MPa, 50 MPa, 20 MPa, respectively. The most distal part of the femur was fixed while the pelvis was displaced to -1.5 mm to simulate load.
Findings / Results: The result indicates that the symmetry of the hip joint of the unilateral Perthes’ case was altered biomechanically. The highest displacement of the healthy hip occurred at the supero-medial side of the femoral head. On the other hand, in Perthes’ hip, the displacement occurred at the superior part of the femoral head and gradually reduced towards the distal part of the femur. Localized contact pressure and stresses were also found in the Perthes’ hip.
Conclusions: As a mechanical analogy, the healthy hip is experiencing bending load similar to a curved-cantilever beam where the maximum displacement is located at the end. The Perthes’ hip resembles a stacked column structure where the load is transmitted through compression. This indicates an aggravation of Perthes’ disease because bone overloading by compression around the proximal part might occur. The FE method developed in this study can be used to estimate the prognosis of the Perthes' disease.

184. The EOS imaging system: Workflow and radiation dose in scoliosis examinations
Bo Mussmann, Stig Jespersen, Trine Torfing
Department of Radiology, Odense University Hospital; Department of Orthopedic Surgery, Odense University Hospital

Background: The EOS imaging system is a biplane slot beam scanner capable of full body scans at low radiation dose and without geometrical distortion. It was implemented in our department primo 2012 and all scoliosis examinations are now performed in EOS. The system offers improved possibility to measure rotation of individual vertebrae and vertebral curves can be assessed in 3D. Leg length Discrepancy measurements are performed in one exposure without geometrical distortion and no stitching. Full body scans for sagittal balance are also performed with the equipment after spine surgery. Purpose
Purpose / Aim of Study: The purpose of the study was to evaluate workflow defined as scheduled time pr. examination and radiation dose in scoliosis examinations in EOS compared to conventional x-ray evaluation.
Materials and Methods: The Dose Area Product (DAP) was measured with a dosimeter and a comparison between conventional X-ray and EOS was made. The Workflow in 2011 was compared to the workflow in 2013 with regards to the total number of examinations and the scheduled examination time for scoliosis examinations.
Findings / Results: DAP for a scoliosis examination in conventional X-ray was 185 mGy*cm2 and 60.36 mGy*cm2 for EOS. The scheduled time for scoliosis was 15 minutes in conventional X-ray which remained unchanged after implementation of EOS. The number of scoliosis examinations has increased from 396 to 1.145 since the implementation.
Conclusions: The radiation dose for a scoliosis examination in EOS can be reduced to approximately 30 % of the radiation dose in conventional X-ray. The increased number of scoliosis examinations is related to increased referral and not due to optimized workflow.

185. Stand-alone XLIF; 22 Consecutive patients with degenerative scoliosis and foraminal stenosis a 2 year follow-up
Emil Hansen
Sector for Spine surgery and Research, Middelfart Hospital

Background: The extreme lateral approach to the intervertebral spaces in the lumbar and thoracic spine is a procedure developed to allow a larger footprint cage to be inserted when performing spondylodesis. In the litterature not many studies have been made to investigate the role of the cage as a stand-alone option for degenerative scoliosis. While the patients often are fragile and with poor bone quality, a single surgical option, preserving the posterior structures, could be beneficial.
Purpose / Aim of Study: The purpose of the study is to evaluate the complication rate and clinical/radiological results in DS patients undergoing spondylodesis with a XLIF stand-alone procedure
Materials and Methods: 22 consecutive patients with DS, underwent surgery with the XLIF stand-alone procedure, follow-up 24 months. Validated clinical outcome scores were collected preoperatively, at 1 and 2 years. Complications were recorded.
Findings / Results: 22 patients with a mean age of 65 (48-81) underwent surgery on 49 levels (1-4) between L1-L5. Visual Analog scores for leg pain improved from 59,4-34,9 (P<0,05) and back pain from 59,1-36,8 (P<0,05). EQ5D scores improved from 0,29-0,62 (P<0,05). 7 patients (31,8 %) underwent revision surgery. Osseous fusion was obtained in 53% of the treated levels at 1 year. Anterior thigh pain was recorded in 12 patients postoperatively but only 2 had consistent sypmtoms at 1 year follow-up.
Conclusions: The XLIF stand-alone procedure is a relatively safe procedure compared with other surgical alternatives as ALIF and PLIF. Our results show a significant improvement in clinical outcome scores during 2 year follow-up. Stand alone XLIF should only be advised for single-level and only mild deformity. In most cases we recommend posterior instrumentation.

186. Early surgical stabilization of rib fractures using a minimally invasive procedure: a pilot study
Kiran Anderson, Jesper RAvn, Henrik Eckardt
Ortopædkir. afd. , Rigshosptialet; Thoraxkir. afd. , Rigshosptialet; Ortopædkir. afd., Rigshospitalet

Background: In spite of considerable development in surgical fracture treatment, most patients with rib fractures are still treated non-operatively, although the respiratory consequences of rib fractures may have severe impact on the prognosis after severe trauma. Recently, a number of studies have suggested that a more active approach may decrease the number of days on ventilation as well as reducing long-term pain in these patients.
Purpose / Aim of Study: The purpose of the present study was to report our initial experience with early surgical stabilization using a minimal invasive procedure of open reduction and internal fixation of multiple rib fractures.
Materials and Methods: 12 consecutive patients received in our level 1-traumacenter with one of the following inclusion criterias were operated: flail chest with at least two rib fractures on two adjacent ribs or four adjacent dislocated rib fractures. The basic principles were: A. No osteosyntesis of costa # 1, 2 or 3. B. Operative fixation of only dislocated ribs. In ribs with multiple fractures only one fracture was stabilized. C. Small incisions with minimal dissection of muscle tissue.
Findings / Results: None of the patients had postoperative infections, seromas or wound problems. Skin incisions were 10-15 cm. The average number of costae fixated was 3. Postoperation time in ICU averaged 2,8 days. Postoperative number of days on assisted ventilation averaged 1,16 days. Total number of admission days postoperatively averaged 9,6 days. Lung function at 3 month was equal to background population.
Conclusions: Rib fracture stabilization is a safe procedure that can be performed with small incisions, without transection of muscles and with low morbidity. The intraoperative impression is that operative fixation provide sufficient stabilization for unstable chestwalls and provides a normal lung function.

192. Ewings´sarcoma of the calcaneus treated by limb sparing surgery with calcanectomy and reconstruction with a composite of an allograft and a vascularised osteocutaneous fibula graft.
Werner Hettwer, Lisa Toft Jensen, Michael Mørk Petersen
Musculoskeletal Tumor Section, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen; Department of Plastic Surgery, Rigshospitalet, University of Copenhagen

Background: Primary malignant bone tumours of the calcaneus are very seldom. Due to poor possibilities to do surgery with wide margins in this region and limited options for reconstruction after calcanectomy many orthopaedic oncologists use amputation as the preferred surgical treatment.
Purpose / Aim of Study: We present two cases of Ewings´sarcoma of the calcaneus treated with limb sparing calcanectomy and reconstruction with a composite of an allograft and a vascularised osteocutaneous fibula graft.
Materials and Methods: Case 1: a girl, almost 6 years old at the time of calcanectomy of the left calcaneous August 7th 2012. Case 2: a girl 16 years old at the time of right calcanectomy October 16th 2013. Both patients received pre- and post- operative chemotherapy because of Ewings ´sarcoma. In both cases removal of the calcaneus was performed using a combined medial and lateral incision. In case 1 a femoral head allograft was fitted to replace the removed calcaneus, and in case 2 a calcaneus allograft was used. In both cases, with the aim of obtaining arthrodesis, the allograft was fixed to the talus and cuboid bone with Acutrak titanium screws. A distally pedicled osteocutaneous flap was used for reconstruction of soft tissue, and a 5-6 cm piece of vascularised fibula bone was fitted into the allograft and fixed using staples.
Findings / Results: Case 1 was allowed weight-bearing in an ankle brace after 3½ months and full weight- bearing with-out brace 8 months postoperatively, when the arthrodesis between allograft and talus was considered healed. Case 2 was allowed increasing weight-bearing in a ROM walker 7 months postoperatively, when the arthrodesis between allograft and talus was considered healed.
Conclusions: Limb sparing calcanectomy was feasible with reconstruction using a composite of an allograft and a vascularised osteocutaneous fibula graft.