Session 16: Poster med foredrag C

Onsdag 21. oktober
11:00 – 12:00
Lokale: Helsinki / Oslo
Chairmen: Søren Eiskjær / Ole Rahbek

162. Conventional Supine MRI with a Lumbar Pillow an alternative to Weight-Bearing MRI for diagnosing functional spinal stenosis? A Cross-Sectional Study
Bjarke Brandt Hansen, Philip Hansen, Mikael Boesen
The Parker Institute, Department of Rheumatology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark; Department of Radiology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.

Background: An important aspect of Lumbar Spinal Stenosis (LSS) is the relationship between posture and symptoms, which are often accentuated when standing, walking or with spinal extension. It is well known that the dimensions of the spinal canal increases with flexion and decreases with extension.
Purpose / Aim of Study: To investigate if a lumbar pillow is comparable to standing weight-bearing MRI for diagnosing functional LSS
Materials and Methods: Clinical MRI scans were screened for a single level moderate LSS defined by a Dural Cross-Sectional Diameter (DCSD) between 7-10mm. If present, the patient was asked to participate in this study, where a second scan in a (0.25T) open G-MRI unit was performed in: 1) standing 2) the conventional supine position with a pillow under the legs and 3) supine position with extended legs and a lumbar pillow. The L2- S1 lumbar lordosis angle (LA), Spinal Cross-Sectional Diameter (SCSD), Dural Cross-Sectional Diameter (DCSA) and DCSD were measured in each position.
Findings / Results: Twenty-seven patients (mean age 60.6 years; ±9.4) were included. All had increasing symptoms while standing or extending their lumbar spine. The LA increased significantly when changing from supine to the standing posture (MD: 3.4; P<0.001) and with the lumbar pillow (MD: 13.1; P<0.001). One-way ANOVA for repeated measurements indicated significant differences between positions (P<0.001). The following pairwise comparison showed decreased SCSD, DCSA and DCSD in both standing weight- bearing position and with the lumbar pillow compared to the conventional supine position (P<0.001). Higher average pain scores (VAS) were reported during scans with the lumbar pillow (5.4±2.7) than standing (4.0±2.7) and the conventional position (3.6±2.8).
Conclusions: A lumbar pillow may be an inexpensive method to improve the supine MRI diagnostics of functional LSS.

163. Rate of unsuspected malignancy in patients with vertebral compression fracture undergoing percutaneous vertebroplasty
Emil Jesper Hansen, Ane Simony, Mikkel Østerheden Andersen, Leah Carreon
Rygkirurgisk sektor, Middelfart Sygehus

Background: Osteoporotic vertebral compression fractures (VCF) affect approximately 20% of postmenopausal women and can lead to long-term disability. Percutaneous Vertebroplasty (PVP) is a minimally invasive procedure, primarily used in patients with severe pain after VCF. Even with a thorough clinical examination, MRI scans and blood samples, some fractures maybe caused by an underlying malignant disease.
Purpose / Aim of Study: To determine the malignancy rate and histology in bone biopsies obtained during PVP for VCF.
Materials and Methods: 144 consecutive patients underwent PVP for painful VCF, at the Center for Spine Surgery and Research, Middelfart Hospital. All patients had bone biopsies obtained during the PVP, and these biopsies were sent to the Department for Pathology at Vejle Sygehus for histologic diagnosis.
Findings / Results: 144 patients were included in this study. The majority of the biopsy specimens (137, 95,1%) were acceptable for histological diagnosis. 129 (89.6%) of the biopsies showed no signs of malignancy. Seven (4,9 %) were positive for malignancy. 1 biopsy was positive for MGUS. Seven (4.9 %) of the biopsies were unsuitable for histologic diagnosis.
Conclusions: Our study shows an incidence of unsuspected malignancy in biopsies during PVP of 4.9 %. Conservative treatment with analgesics and brace can potentially delay diagnosis and treatment of underlying malignant disease. We recommend biopsy during PVP as a standard-procedure, to insure not to overlook any underlying malignancy despite the MRI-scan, blood analysis and clinical examination being inconspicuous.

164. Selective motor branch block of the rectus femoris as diagnostic tool before surgical rectus transfer
Stig Sonne-Holm, Derek Curtis, Hanne Bloch Lauridsen, Billy Kristensen, Jesper Bencke
Dep. of Orthopaedic Surgery & Laboratory of Gait and Human Movement, Hvidovre Hospital; Laboratory of Gait and Human Movement, Hvidovre Hospital; Dep. of Anesthesiology, Hvidovre Hospital

Background: Stiff knee gait is defined as decreased knee flexion in the swing phase of gait, and may be due to hyper activity in the rectus femoris (RF), the whole quadriceps muscle and/or tightening of the muscles, Surgical RF transfer may not improve gait, if other factors than the RF is influencing gait.
Purpose / Aim of Study: The purpose was to investigate if pre-surgery selective motor branch block (SMBB) of the RF may predict outcome of subsequent RF transfer surgery.
Materials and Methods: Seven patients with hemi- or diplegic cerebral palsy and with stiff knee gait, age 11-55, 3 males and 4 females were included in the study. Biomechanical gait analyses (GA) were performed before and after SMBB using a local anaesthetic. Maximal knee flexion in swing phase obtained from pre- and post lidocain GA as well as from a 12 months post- surgery GA was compared using non-parametric statistics.
Findings / Results: In one patient the nerve block acted on the entire femoral nerve, this patient was therefore excluded from this study. One patient declined surgery due to a less than 2 degrees improvement by SMBB and was therefore excluded. The remaining five patients showed better gait function following the block and at follow up 12 months after RF transfer surgery. The range of motion in swing phase increased significantly from median 32.3 to 38.6 degrees (p=0.043) after SMBB and 12 months after RF transfer surgery to 51.3 degrees (p=0.043).
Conclusions: The present study on preliminary data therefore indicates, that SMBB of the RF may be a feasible way to predict positive outcome of RF surgical transfer in patients with stiff knee gait. However, post-surgery data on patients with negative results of SMBB would be necessary in order to perform a proper sensitivity analysis for this new diagnostic tool. It was not possible in this study for ethical reasons.

165. TheStaRT Back Sreening can predict pain problems after spine surgery.
Lisbeth Storm, Rikke Rousing, Leah Carreon, Mikkel Østerheden Andersen
Center for spine surgery and research, Middelfart, sygehus lillebælt

Background: Following spine surgery a number of patients develop complex pain problems. To prevent these problems, it is important to identify these patients before surgery in order to optimize their postoperative pain management. A simple and convenient tool is needed to identify these patients.
Purpose / Aim of Study: To investigate if the STarT Back Screening Tool can identify patients in risk of developing complex pain after spine surgery. This tool separates the patients into low, medium or high risk of developing complex chronic pain. STarT has not been tested on surgical patients.
Materials and Methods: Patients who had a lumbar spine surgery in our department during a 3- month period completed the STarT Back Tool preoperatively. Postoperatively their back and leg pain were scored on a visual analogue scale (VAS) day one after surgery and at discharge. The score was repeated four or twelve weeks after surgery. The VAS -scores preoperatively and at 1-year follow-up were acquired from DaneSpine
Findings / Results: There were 255 patients (93%) rated by the STarT Bach Tool. Of these 139 (54%) were in the high risk group, 83 (33%) in the medium risk group, and 33 (13%) in the low risk group. At discharge patients in the high risk group had higher back and leg pain scores compared to the patients in the medium and low risk groups. This did not reach statistical significance. Follow-up data, 4 or 12 weeks postoperatively from 222 (87%) patients showed that patients in the high risk group had statistically significantly higher back and leg pain scores compared to the patients in medium and low risk group. This difference were also statistically significant at 1-year follow- up.
Conclusions: The STarT Back Screening Tool can predict prognoses in short and long term, but it does not predict pain problems in the perioperative phase.

166. Arthroscopic evaluation of degenerative changes in the trapeziometacarpal joint
Lone Kirkeby, Lene Dremstrup, Hansen Torben Bæk
University clinic for hand-, hip- and knee surgery, Regional Hospital Holstebro, Aarhus University

Background: Osteoarthritis of the trapeziometacarpal joint is common in postmenopausal women and men above the age of 50. Younger patients may however present clinical symptoms of osteoarthritis without significant degenerative signs on radiographs.
Purpose / Aim of Study: To evaluate the effectiveness of arthroscopy in evaluation of suspected degenerative changes of the trapeziometacarpal joint in cases with only minor radiological changes.
Materials and Methods: We retrospectively evaluated the result of 13 arthroscopies of the trapeziometacarpal joint in 13 patients (2 males and 11 females) mean age 46 years (range 19-58) with persistent pain in the trapeziometacarpal joint at rest and activity but with only minor or no degenerative findings on radiographs or CT scan. Post traumatic osteoarthritis was suspected in 4/13 patients aged 19-51, and in the remaining 11 patients primary osteoarthritis was suspected.
Findings / Results: In all patients degenerative changes were found ranging from cartilage degeneration in part of the joint to denuded bone at both sides of the joint. In 9/13 the changes were so severe, that the patients were treated with further surgery such as total joint arthroplasty. In four patients a clear diagnosis was found, but so far further surgery has not been performed.
Conclusions: Arthroscopy seems effective in diagnosing degenerative changes of the trapeziometacarpal joint in cases with none or only minor radiological changes but persistent and significant clinical symptoms of osteoarthritis.

167. Revison procedures do not affect survival after surgical treatment of acute metastatic spinal cord compression (MSCC).
Maria Ferm Eisenhardt, Søren Schmidt Morgen, Martin Gehrchen, Sidsel Fruergaard, Benny Dahl
Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet and University of Copenhagen

Background: Spinal metastases occur frequently in patients with oncological conditions and patients with acute MSCC may benefit from surgical treatment followed by radiation therapy. Due to the poor general condition in the majority of these patients, revision surgery may result in significant morbidity.
Purpose / Aim of Study: The purpose of the present study was to assess the impact of revision procedures on survival in patients undergoing surgical treatment for acute MSCC. Hypothesis: Revision procedures after surgical treatment of acute MSCC affect survival negatively.
Materials and Methods: Design: Single-center, prospective, cohort study. Methods: All patients undergoing acute surgery for MSCC in the period January 1st, 2008 through December 31st, 2013 were prospectively enrolled in a clinical database. All relevant variables were registered and survival status per December 31st, 2014 was retrieved through the National Health Service.
Findings / Results: A total of 556 patients were included in the six-year study period with a minimum follow- up of one year. Twelve patients had emigrated or were non-Danish citizens, resulting in a 98% data completion comprising 544 patients in the final study population. The mean age of the patients was 64 years and 57% of the patients were men with no significant difference in survival between genders. The primary location of the metastasis was thoracic (55%) and 74% of patients underwent instrumented procedures. At least one revision was carried out in 45 patients corresponding to an overall revision rate of 9%. There was no significant difference in survival between patients undergoing revision and patients who only underwent one procedure; mean 566 days vs. 489 days (P=0.4).
Conclusions: Revision surgery does not affect survival in patients operated for acute MSCC

168. Evaluation of cell binding peptide (P15) in silk fibre enhanced hydroxyapatite bone substitute for posterolateral spinal fusion in sheep
Martin Glasdam Axelsen, Stig Mindedahl Jespersen, Søren Overgaard , Ming Ding
Department of Orthopedic Surgery, Institute of Clinical Research, Odense University Hospital, University of Southern Denmark; Department of Orthopedic Surgery, Odense University Hospital

Background: Posterolateral fusion (PLF) is indicated in the surgical management of various spinal disorders. To ensure stabile fusion, bone graft materials are used.. CE approved ABM/p15 (Anorganic Bone Matrix) has in a previous preclinical study from our group shown extensive ability of migration when used in uninstrumented PLF. In this study, silk fibers were added to the graft material to make a mesh for the ABM/p15 granules. Silk fibers have high biocompatibility and strength. P15 is a synthetic, 15 amino acid peptide sequence, with osteoinductive properties. In this study we investigate the effect of P15 peptide when coated on ABM combined with a silk fiber mesh
Purpose / Aim of Study: Compare fusion rates using silk fibre enhanced ABM with or without P15 peptide in uninstrumented PLF
Materials and Methods: Two level uninstrumented PLF at L2/L3 and L4/L5 were performed in 12 sheep. Levels were randomised to silk fibre enhanced ABM bone graft with or without P15 coating bilaterally. After 4.5 month, levels were harvested and evaluated with MicroCT 50 scans and qualitative histology. Fusion rates were assessed with 2D sections and 3D reconstruction images and fusion was defined as intertransverse bridging
Findings / Results: Spinal fusion was found in 72% of levels receiving silk fibre enhanced ABM/P15 graft material and 41% in levels without P15 (P<0.05). No major migration was detected. Histology indicated more bone formation in P15 group with laminar initiation. In both groups good osteointegration was found.
Conclusions: P15 peptide enhanced fusion rates when coated to ABM in silk fibre enhanced bone graft. Reported fusion rates are equal to earlier reported rates using allo- or autograft. This preclinical study indicates that silk fibre enhanced ABM/P15 is a potential graft material for clinical use which should be evaluated in a controlled clinical study

169. Revision of total wrist arthroplasty
Michel E. H. Boeckstyns, Guillaume Herzberg
Clinic for Hand Surgery, Gentofte Hospital; Unit for Wrist Surgery, Edouard Heriot Hospital, Lyon University

Background: Third generation implants for total wrist arthroplasty (TWA) has now been available for more than 17 years. Consequently, an increasing number need revision.
Purpose / Aim of Study: To report on our experience with revision surgery after failed TWA
Materials and Methods: We prospectively and consecutively collected data on all TWA's that were revised in two clinics and made a general follow-up examination in May - June 2015.
Findings / Results: We revised a total of 19 cases: 8 with rheumatoid arthritis, 11 with other diagnoses. 12 were revised to a Remotion TWA, 1 to an Amandys interposition implant and 6 were fused. At final follow-up, at an average of 31 months after operation, median improvement in QuickDASH score was 25 points, median improvement in VAS- score for pain was 50 points. 3 revision TWA had been re-revised and 1 was loose and scheduled for re-revision. There was no difference in QuickDASH- or in VAS-score between patients with fusion and patients with TWA.
Conclusions: Both fusion and revision to a new TWA are feasible after a failed TWA. Revision to a new TWA may require supplementary major procedures.

170. 3D Correction by CB Growth Rod Concept in Severe Deformities of the Immature Spine (EOS)
Simon Toftgaard Skov, Barbara Jensen, Haisheng Li, Ebbe Stender Hansen, Kristian Høy, Cody E. Bünger
Ortopaedic dep. E, Aarhus University Hospital; Orthopaedic Research Lab., Aarhus University Hospital

Background: Management of severe EOS should ensure a 3D-correction with preserved pulmonary function and truncal growth. We have developed a novel growth rod concept.
Purpose / Aim of Study: Aims of this study were to 1) analyse 3D- curve-correction and truncal height and 2) monitor adverse events.
Materials and Methods: 34 patients have been treated with the new concept based on 4.5 mm pediatric implants since 2010. We excluded patients with less than 2 years follow-up (n=13) and complex salvage procedures (n=2). The study group of 19 patients has a mean follow-up of 3.0 years(2.1-3.9), mean age at index surgery 9.8 years(4-14) and mean scoliosis Cobb angle 77°(47-129). Etiologies: neuromuscular(n=9), idiopathic(n=4), and others(n=6). The tripple rod system is mounted on pedicle screws in 3 platforms, cranial, apical and caudal, using minimal invasive technique. Deformity correction is achieved by concave distraction, apical translation and derotation by applying apical compression. Lengthening as a one day procedure every 6 months until skeletal maturity by concave distraction and locking, leaving convex growth tubes unlocked.
Findings / Results: Index surgery decreased scoliosis Cobb by median 37°(15-68). Thoracic hyperkyphosis decreased, without significant change in lordosis. Torsion was corrected by 14% with partial loss over time. Truncal height assessed as T1-S1 on digital x-rays, increased by 0,9±0.7 cm/year. 16 adverse events in 11 patients. Six complications lead to unintended reoperation (32%). Asymptomatic metal debris (n=6).
Conclusions: Our triple growing rod concept proves 3D- correction in the surgical management of severe EOS. Complication rate is 32%. Further improvement on rotatory control and prevention of metal debris needed.

171. Risk factors for recurrent lumbar disc herniation
Stina Brogård Andersen, Elisabeth Corydon Smith, Christian Støttrup, Mikkel Andersen
Center for Spine Surgery and Research - Middelfart, Sygehus Lillebælt

Background: The rate of recurrent lumbar disc herniation (rLDH) following lumbar discectomy varies from 3-11 % and thereby being the most common complication. Though many studies have reported the rate of rLDH, few have provided statistical evidence of risk factors. Current literature reports multiple risk factors, however with diverging incidence. Overall, the current literature provides limited certainty regarding risk factors of rLDH.
Purpose / Aim of Study: The purpose of the present study is to examine if age, gender, smoking habits and BMI are risk factors for rLDH.
Materials and Methods: All patients who underwent primary lumbar discectomy due to LDH at Lillebaelt Hospital from June 2009 to January 2015 were included. Self reported data on age, gender, smoking status and BMI were prospectively collected in the database DaneSpine. All statistical analyses were carried out using STATA version 12.1.
Findings / Results: A total of 1572 patients were included. 124 patients (7,9%) were re-operated; 109 patients (7,0%) due to rLDH. Other reasons included persisting stenosis, cerebral spinal fluid fistula, etc.. The mean age was significantly lower in the rLDH group (48,3(CI 47,5;49,0) vs. 44,7(CI 42,5;46,9)) (P=0,01). The rate of smokers was significantly higher in the rLDH group (34% vs. 53%)(P=0,001). There was no statistical difference in gender or BMI between the two groups.
Conclusions: The rate of rLDH in the present study corresponds to results presented in previous studies. We found that the mean age was lower in the rLDH group and that the rate of smokers was higher. We can also conclude that the rate of smokers in the total surgery group was higher than in the general Danish population. This indicates that smoking not only increases the risk of rLDH and there seems to be a higher prevalence of smokers among patients undergoing lumbar discectomy.

172. Treatment of Pathologic Acetabular Fractures with Tri-flange Reconstruction Cage
Elinborg S. Mortensen, Peter Horstmann, Michala S. Sørensen, Werner Hettwer, Michael M. Petersen
Musculoskeletal Tumor Section, Department of Orthopedic Surgery, Copenhagen University hospital, Rigshospitalet

Background: Periacetabular reconstruction for metastatic bone disease (MBD) can be accomplished with a composite construct of PMMA and any combination of metal augments, mesh, pins, cages and/or plates. Reinforcement of such constructs by trans-iliac Steinmann pin fixation according to the technique described by Harrington, is typically recommended for more extensive lesions involving the acetabulum.
Purpose / Aim of Study: To investigate results when treating MBD acetabular fractures with tri- flange reconstruction cages without the use of trans-iliac Steinmann pin fixation.
Materials and Methods: We performed a retrospective review of a consecutive cohort of adult patients with MBD, who underwent endoprosthetic reconstruction because of pathologic acetabular fractures in our department between January 2008 and September 2014. We identified 18 patients (F/M=11/7) with a mean age of 70 (49-92) years, who received a standard, long flanged stainless steel cage (Link partial pelvis replacement). Cemented acetabular components (Lubinus Eccentric) were used in all patients.
Findings / Results: Seven patients succumbed to their disease within the first year after operation (probability of 1-year overall survival 61%). 4 complications required second intervention. Two dislocations were observed within the first year and were treated with implantation of a constrained devise. One patient had revision of wound. One patient suffered from deep infection and is currently undergoing 2-stage revision. All patients but one regained ambulatory function and we did not observe any failures of the pelvic reconstruction constructs.
Conclusions: Our findings suggest that standard tri- flange pelvic reconstruction cages can be a valuable treatment option in the management of pathologic acetabular fractures.