Session 5: Pediatric / Foot
Torsdag den 22. oktober
09:00 – 10:30
Lokale: Stockholm/Copenhagen
Chairmen: Vilhelm Engell / Jeannette Ø. Penny
49. The effect of early vs. late weightbearing in conservatively treated acute Achilles tendon rupture: A meta- analysis
Ali Imad Akkawi, Cand.med, Rajzan Joanroy, Cand.med, Kristoffer Weisskirchner Barfod, MD, PhD, Thomas Kallemose, statistician, Søren Skydt Kristensen, MD, Prof, Dr.Med, Bjarke Viberg, MD, PhD
Odense, University of Southern Denmark; Clinical Orthopedic Researh, Dept of Orthopedics, Copenhage university hospital, Hvidovre; Clinical and research department, Copenhagen university hospital, Hvidovre; Dept of Orthopedics, Odense university hospital
Background: Achilles tendon ruptures can be
conservatively treated with immobilization
and early functional mobilization but early
weight bearing is more uncertain.
Purpose / Aim of Study: To conduct a meta-analysis comparing the
effect of early versus late weight bearing in
conservatively treated Achilles tendon
ruptures in adult patients. Primary endpoint
was re-rupture and secondary endpoints
were strength, ’Quality of life during
treatment’, range of motion, deep venous
thrombosis, return to sport, and return to
work.
Materials and Methods: A search string was constructed using the
keywords “Achilles tendon” and “rupture”
and applied in PubMed, EMBASE and The
Cochrane library. Two reviewers
independently screened the studies by title,
then by abstract and finally by full text
reading. 3 studies met the inclusion criteria.
The reference lists of the included studies
were screened and 1 further RCT study was
included. Experts on this field were asked
and no further studies were identified. The
CASP checklist was applied for the study
appraisal.
Data was extracted according to the
purpose of this study. For the meta-
analyses the Mantel-Haenszel method was
used for the effect estimates. A fixed effect
model was chosen. and the results were
presented in forest plots.
Findings / Results: There were no statistically significant
differences between the two treatment
groups concerning re-rupture: OR 0.99 (95
% CI 0.31; 3.18), p= 0.981, return to sports:
OR 1.34 (0.62; 2.90), p= 0.455, and return
to work: MD (Mean difference) 1.62 (-20.89;
24.13), p= 0.888. For the other endpoint it
was not possible to conduct a meta-
analysis.
Conclusions: There was no statistically significant
difference between early and late weight
bearing in conservative treatment of Achilles
tendon rupture concerning the outcomes of
this study.
50. The effect of 15 minutes postoperative daily arm bicycling on oxygenation of the soft tissue after total ankle replacement
Claus Sundstrup, Niels Christian Jensen, Kristian Kibak Nielsen, Frank Linde
Foot and Ankle Section, Department of Orhtopaedics, Aarhus University Hospital; Foot and Ankle Section, Department of Orthopaedics, Aarhus University Hospital
Background: Wound healing complications after total
ankle replacement are reported as
frequent as 30%. Although most minor,
they are occasionally serious and may
lead to loss of the prosthesis. Recent
studies have shown that the
oxygenation of the soft tissue around
the ankle decreases significantly the day
after total ankle replacement, and does
not reached normal level until the 6th
postoperative day.
Purpose / Aim of Study: The purpose of the present study was
to study the effect of postoperative
exercise by arm bicycling in the bed on
the oxygenation of the soft tissue at the
lower leg.
Materials and Methods: Eleven patients who had a total ankle
replacement had a 15 minutes training
session every postoperative day until
the 4th postoperative day. The training
intensity was individually adjusted to
approximately 70% of maximal level.
Trancutaneous oxygen tension (tcpO2)
was measured at the operated ankle
using the Radiometer TCM400 system.
TcpO2 of the non-operated ankle and
the upper part of both lower legs served
as controls. TcpO2 was measured
preoperatively and every postoperative
day at rest (before exercise), during
exercise, and during restitution.
Findings / Results: TcpO2 at the operated ankle decreased
from median 58 mmHg preoperatively to
median 22 mmHg the 1st postoperative
day. TcpO2 at rest the following 3 days
was 15 mmHg, 9 mmHg and 13 mmHg
respectively. During exercise tcpO2
increased to 44 mmHg, 34 mmHg, 22 mm
Hg, and 23 mmHg (p<0,05, Wilcoxon sign
test). However, after exercise, tcpO2
had decreased to the pre-exercise level
within 30 min.
Conclusions: The postoperative oxygenation of the
soft tissue around the ankle after total
ankle replacement increased
significantly during arm exercise.
However, the effect on tissue
oxygenation vanished within 30 min.
rest.
51. The flexible adult flatfoot. An evaluation of three different etiology-pathogenesis hypotheses. A case-control study.
Lotte Dalsgaard Petersen, Merete Frick Jeopsen, Henrik Lopdrup, Frank Linde
School of Physiotherapy, VIA University College, Aarhus ; Foot and Ankle Section, Department of Orthopaedics, Aarhus University Hospital
Background: Several hypotheses have been
proposed for the etiology and the
pathogenesis of the flexible flatfoot.
Purpose / Aim of Study: The purpose was to test three different
hypotheses. 1) a short Achilles tendon,
2) increased laxity of the 1st ray, 3)
incomplete axial rotation of the medial
ray in relation to the lateral ray of the
foot.
Materials and Methods: 16 young adults (20-29 years) with a
flexible flatfoot were selected from a
group of 65 volunteers. A flatfoot was
defined as a foot fulfilling two criteria:
The Foot Posture Index (FPI-6, Redmond
2005) above 7 and the heel in more than
5 degrees valgus in the weight bearing
position.
16 volunteers with neutral feet matched
for sex, age, weight and foot length
served as controls. The length of the
Achilles tendon was determined as the
degree of dorsiflexion of the ankle
examined with the person in the prone
position with the knee flexed 90 degrees
and the heel in neutral position. The
stability of the first ray was determined
as the dorsal-plantar laxity in relation to
the second ray. The axial rotation
(pronation) was measured with the
ankle and the heel fixed in neutral
position as the maximal pronation of the
forefoot.
Findings / Results: The length of the Achilles tendon in the
flat foot group was median 28 degrees
compared to 24 degrees in the control
group (p=0,024, Wilcoxon test). Laxity of
the 1 ray was median 6 mm in the flat
foot group compared to 4 mm in the
control group (p=0.006). No significant
difference was found regarding
pronation of the foot.
Conclusions: It is a general statement that the flexible
flat foot is associated with a short
Achilles tendon. It could not be
demonstrated in this group of young
adults. In contrary the Achilles tendon
was found to be longer in the flat foot
group. This study support general laxity
as the most probable etiology for the
flexible flatfoot.
52. Achilles Tendon Total Rupture Score at 3 months can predict patient’s ability to return to sport at 12 months. A registry study on 366 patients from the Danish Achilles Tendon Database.
Maria Swennergren Hansen, Marianne Christensen, Thomas Budolfsen, Thomas Kallemose, Anders Troelsen, Kristoffer Weisskirchner Barfod
Physiotherapy, Danish Achilles Tendon Database, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark; Occupational therapy and Physiotherapy, Orthopaedic surgery, Danish Achilles Tendon Database, Aalborg University Hospital, Denmark; Physiotherapy, Danish Achilles Tendon Database, Copenhagen University Hospital, Hvidovre, Denmark; Danish Achilles Tendon Database, Clinical Orthopaedic Research Hvidovre, Clinical Research , Copenhagen University Hospital, Hvidovre, Denmark; Orthopaedic surgery, Danish Achilles Tendon Database, Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
Background: It is desirable to identify predictors of
outcome after acute Achilles tendon
rupture in order to individualize
treatment. It is unknown if the Achilles
tendon Total Rupture Score (ATRS)
correlates to patients ability to return to
sport and work. The Danish Achilles
Tendon Database (DADB) was
founded in 2012.
Purpose / Aim of Study: To investigate how ATRS 3 and 12
months after injury correlates with the
patient’s ability to return to work and
sport. Furthermore to investigate if sex
and age influences ATRS 3 and 12
months after injury.
Materials and Methods: This is a retrospective study analyzing
data from DADB including 366 patients
from 5 hospitals in Denmark. Logistic
regression was conducted to describe
the effect of ATRS on return to work
and sport after 1 year (adjusted for age
and sex). The effect of age and sex on
ATRS was analyzed by linear
regression.
Findings / Results: Three months after injury patients had
a significantly increased chance for
return to sport after one year with
increased ATRS score (OR = 1.06 for
each point, CI = 1.02-1.09, p = 0.002),
but non-significant effect for work.
After one year patients had a
significantly increased probability of
having returned to sport (OR =1.11, CI
= 1.05-1.17, p < 0.001) and returned to
work (OR = 1.05, CI =1.01-1.09, p =
0.007) with increased ATRS score.
Men had an average 6.6 (CI = 1.9 -
11.4, p = 0.006) point higher ATRS
score at 3 months and average 22.3
(CI = 6.7 – 37.9, p = 0.006) point
higher at 12 month. Age showed no
significant effect on the ATRS score at
3 or 12 month.
Conclusions: ATRS is correlated to patient’s ability
to return to sport and work. ATRS at 3
months can be used as a predictor of
patient’s ability to return to sport one
year after injury. Men obtain a
noticeable higher ATRS score3 and 12
months after injury.
53. 10-year survival analysis of 217 primary Hintegra total ankle artroplasties from an independent center
Mina Zafar, Lars Ebskov, Jeannette Østergaard Penny
Orthopeadic department, Hvidovre Hospital
Background: Total Ankle arthroplasty (TAA) have larger revision
rates than hip and knee prosthetics. Almost half of
all publications concerning TAA come from the
developer’s center, which often publish better
survival rates than those from registries. There are
currently no larger independent survival studies of
the Hintegra TAA.
Purpose / Aim of Study: To examine the indications for and survival rates of
our primary Hintegra TAAs and what different
factors affect the success and/or revision-rate.
Materials and Methods: 487 surgeries between 2004-2014 coded as ankle
implant was reviewed. 217 were operated with a
primary Hintegra TAA, 109 female and 108 males,
median age 61 (23 to 80). We used the 2nd
generation implant (CrCo-HA coating) until 2007
and 3rd generation (Ti-HA coating) from 2008.
Cause of OA, revision surgery and reason to revise
was recorded. A Cox proportional hazard model
evaluated gender, age, cause of OA and implant
generation as risk factors.
Findings / Results: 62 implants were revised. The cause of revision was
pain (18), loosening (18), infection (12) or mixed
others (14). The 5 year survival rate (95% CI) was
72 (62-80) %, 7 year = 64 (55-75) % and 10 year =
47 (29-76) %. Fifty nine percent of the 217 primary
implants had post traumatic OA, 32% idiopathic and
9% RA, which had no impact on revision risk. Nor
had age or gender. Of the 34 2.nd generation
implants only 11 was revised, making them 5 times
(1 to 18) less likely to be revised (p= 0.02).
Conclusions: Our revision rates are slightly above the Swedish
registry and well above those of the developer. Our
patients are different but that has no statistical
impact on revision. The larger risk found for the 3rd
generation in this study is not found in the
developers results. Further studies on preoperative
angles and implant position may help clarify our
relative high revision rates.
54. Fracture dislocation of the midfoot (Lisfrancs injury): Early results of ORIF at Koege Hospital
Zaid Issa, Anna Kathrine Pramming, Jens Kurt Johansen
Ortopaedic Department, Koege Hospital
Background: Lisfranc injury (LI) involves ligament
tear, fracture and joint disruption at
the midfoot, involving 1 or more
tarsometatarsal (TMT) joints. LI
constitutes 0,2% of all fractures.
Direct axial force is a common cause of
injury generating tensile forces at the
plantar ligaments of the TMT- joints.
Indirect force generated through
rotation or twisting on a plantarflexed
foot is another cause of injury.
Severity of the soft tissue injury and
non-anatomic reduction are negative
prognostic factors. LI are managed by
foot surgeons at Koege orthopedic clinic
since 2012.
Purpose / Aim of Study: To evaluate results of LI treated by
ORIF over a 3 year period.
Materials and Methods: 15 consecutive patients, 9 males and 6
females, were included. Patients were
identified using ICD10 diagnosecodes.
Medical records and postop x-rays were
reviewed. Radiologic alignment was
accessed. Age ranged from 16 to 73
years, mean age 45 years.ORIF with
screws, bridging plates and in some
cases k- wires were used. Acute closed
reduction and K-wire fixation was done
in 2 cases due to soft tissue concerns,
ORIF was performed secondarily. Primary
arthrodesis of the 1.TMT joint was done
in 1 case.A-VI Foot Pump was used in the
early postoperative fase.Follow-up
ranged from 6-24 weeks
Findings / Results: 11 patients were Grade 1, 4 patients
were Grade 2 on Tscherne Score.10
patients are painfree and have returned
to their pre-injury activities (work and
sports).5 patients have mild pain.1
patient had hardware removal due to
pain. 1 patient had wound breakdown but
healed uneventfully.Anatomic alignment
was achieved in 14 cases.
Conclusions: Outcome of current treatment of LI at
Koege Hospital seems satisfactory
regarding alignment and complication
rate. Long term follow up and patient
related outcome measure is suggested to
provide more information regarding
patient satisfaction.
55. subtalar arthroereisis by minimal invasive surgery
Frantz Nørregaard, Gert Rahbek Andersen
, ; Dept. of Orthopaedics, Rigshospitalet
Background: Calcaneus-valgus often develops in children
with cerebral palsy. This can cause gait
disturbance and pain. There are several
surgical options to correct the valgus
postion. Extra articular subtalo arthrodesis
or arthroereisis are among these, and they
include procedure in sinus tarsi, and are
thereby extensive and irreversibel
procedures. The present study is minimal
invasiv surgery and is reversible.
Purpose / Aim of Study: We want to present our results from charts
to see if our procedure is comparable to
more extensive procedures and to share the
possible risk of failure in our method.
Materials and Methods: 20 feet (11 patients) operated from 2009-
2014 with the present procedure was
retrospectively found from charts from
Rigshospitalet, Copenhagen.
The operative technic was a stab wound
dorsal over the neck of the talus. A K-wire
was inserted through the neck and sinus
tarsi, to the calcaneus, when the hindfoot is
held in a correct hindfoot position. A
cannulated 7 mm screw secure the correct
subtalar joint position, and a low leg cast in
6 weeks allowing full weight bearing.
Findings / Results: 19/20 feet had satisfactory hindfoot position
with no prolonged pain or implant failure.
1/20 feet was found with prolonged pain at
the site of the screwhead, and removal was
necessary.
The international results are comparable
with presented rates of failure in 5-10 % of
the feet.
Conclusions: The present procedure seems to be safe.
The reversability enables the surgeon to try
the internal fixation without the risk of
chronic pain or otherwise unsatisfactory
results
56. Obesity increases risk of deep infection in ankle fracture surgery
Lasse Lykkebo Olsen, Rune Sort, Ann Merete Møller, Stig Brorson
Department of Anaesthesiology , Herlev University Hospital; Department of Orthopaedics, Herlev University Hospital
Background: Surgical site infections are common after
open reduction and internal fixation (ORIF) of
ankle fractures. Deep infections lead to re-
operations, thus adding to both the risks and
cost of the patient course. Smoking, obesity
and alcohol overuse have been suggested
as risk factors for post-operative
complications after ankle fracture surgery
but evidence is limited.
Purpose / Aim of Study: To examine if smoking, obesity and alcohol
overuse are risk factors for developing deep
infection following ORIF of ankle fractures.
Materials and Methods: We retrospectively reviewed all patients
undergoing ORIF of ankle fractures at
Herlev University Hospital from
01.01.2008 to 31.12.2013. Patients, who
were not primarily treated with ORIF or
did not attend the outpatient follow up,
were excluded. We reviewed patient
records and collected demographic-,
surgical- and postoperative data. Deep
infection was defined as being re-
operated on the indication of infection.
We tested for associations to current
smoking (yes/no), obesity (BMI≥30) and
alcohol overuse (exceeding Danish
Board of Health recommendations). We
analysed data using both univariate and
multivariate analyses adjusting for
demographic factors and diabetes.
Findings / Results: 1044 patients were included in the study.
Patients with BMI≥30 were found to have an
increased risk of being re-operated for an
infection both in the univariate (RR=2,08
[1,21:3,59], p<0,05) and multivariate
analysis (OR=2,16 [1,13:4,15], p<0,05).
Alcohol overuse was also found to increase
the risk but this was not statistically
significant (RR=1,70 [1,03;2,78],
p=0,053).We were not able to show any risk
increase connected to smoking.
Conclusions: Obesity increases the risk of deep infection
after primary ORIF of ankle fractures.
57. Seating performance in children with cerebral palsy in relation to hip reconstructive surgery
Line Kjeldgaard Pedersen, Ole Rahbek, Bjarne Møller-Madsen
Department of Childrens Orthopedics, Aarhus University Hospital
Background: Excessive pelvic tilt impedes sitting
function and can cause pressure
ulcers, which might have an impact on
quality of life in children with cerebral
palsy (CP). Seated sagittal plane
anterior tilt is affected by iliopsoas,
hamstring and rectus contraction,
weakness or spasticity. Posterior tilt
with a decreased lumbar lordosis is
seen in hypotonic children or after
scoliosis surgery and is characterized
as a more vertically placed sacrum,
potentially causing painful sitting and
ulcers over the sacro-coccygeal area.
Seated coronal plane pelvic tilt may
display either right or left pelvic
obliquity and is common in children
with tetraplegia, asymmetrical adductor
contractures, scoliosis or hip
dislocation. Seated transverse plane
obliquity presents as rotation of the
pelvis and is primarily seen in relation
to scoliosis.
Purpose / Aim of Study: To assess seating performance and
pelvic tilt in children with CP
undergoing hip reconstructive surgery.
Materials and Methods: Eighteen children with CP, GMFCS III-
V, scheduled for unilateral hip
reconstruction were included. The
Tekscan CONFORMat Seat Sensor
with a resolution of 1 sensor per cm2
and frequency of 66 frames/second
was used for assessing seating
performance with 30 seconds
recordings performed pre- and
postoperatively.
Findings / Results: Analysis of the area, force, pressure,
peak force and peak pressure showed
that all measures decreased on the
operated side after hip reconstruction.
The pressure asymmetry index
decreased (diff: 11%) indicating
decreased coronal plane obliquity. A
decrease of peak pressures (diff: 22
mmHg and 30 mmHg) in the two
columns flanking the midline was seen
postoperatively indicating increased
pelvic anterior tilt and elevation of the
sacrum.
Conclusions: Changes in seated pelvic tilt after hip
reconstruction can be evaluated by
assessment of seating performance.
58. Intra-variability of outcome measures for seating performance and pelvic tilt in 65 healthy children
Line Kjeldgaard Pedersen, Polina Martinkevich, Søren Quist Ege, Sofie Gjessing, Ole Rahbek, Bjarne Møller-Madsen
Department of Childrens Orthopedics, Aarhus University Hospital
Background: Normal sitting function is perceived
instinctly, though many biomechanical
aspects are present in the process of
sitting. The three-dimensional bony
base of support in sitting is formed by
the ischial tuberosities and sacrum.
The interface between body and
support is defined by the sagittal,
coronal and transverse plane pelvic tilt,
which contributes to measures of
pressure distribution, balance and
symmetry. Balance parameters have
been presented. A flexible pressure
mat for measuring seating
performance may be a new method for
analyzing seating performance and
pelvic tilt.
Purpose / Aim of Study: To define outcome measures and
determine the intra-variability of
measures of seating performance.
Materials and Methods: Sixty-five healthy children aged 7-14
years were included at a primary
school. The Tekscan CONFORMat
Seat Sensor with a resolution of 1
sensor per cm2 and frequency of 66
frames/second was used. Three
recordings were done with the child
seated with a relaxed back position,
followed by three recordings with an
up-right back position increasing the
pelvic anterior tilt.
Findings / Results: The measures of area, force, pressure,
peak force and peak pressure
establish a normal material. Intra-Class
Correlations (ICC) for these measures
ranged between 0.87 and 0.99
indicating excellent intra-variability of
the measures of seating performance.
Asymmetry indices comparing left and
right side were calculated. The lowest
index was seen for contact area
indicating good symmetry and the
highest index was seen for peak
pressure. A significant decrease of
peak pressures in the two midline
columns was seen when the back
position was changed to up-right
(p<0.05; p<0.05), reflecting an anterior
pelvic tilt and elevation of the sacrum.
Conclusions: A normal material and a definition of
validated measures of seating
performance have been determined.
59. The pattern of bicycle injuries and the use of helmets among children aged 6-14 years 1980-2014.
Martine Solheim, Jens Martin Lauritsen, Christian Færgemann
Department of Orthopedics and Traumatology, Odense University Hospital
Background: There has been an increase in bicycle
helmet use since 1990. Studies have
shown that the incidence of severe
head injuries can be reduced by 65 %
when wearing a bicycle helmet. Does
the increasing use of helmets change
the injury pattern from bicycle accident
among children seen in an ED.
Purpose / Aim of Study: The purpose of this study was to
describe the injury pattern in bicycle
accidents among children in relation to
the use of a bicycle helmet.
Materials and Methods: We included all children aged 6-14
years with injuries from bicycle
accidents treated at the ED at Odense
University Hospital 1980-2014. Age,
gender, helmet use, and diagnoses
were analyzed. We defined head
injuries as all injuries involving the
head excluding injuries to the face. We
defined severe head injuries as skull
fractures and intracranial injuries
including concussions, intracranial
haemorrhages, lacerations of brain
etc.
Findings / Results: We included 13661 children, 58.8 %
were boys. The use of helmets at the
time of injury increased from 0 to 19.6
% in girls and 16.9 % in boys. There
was a gradual decrease in head
injuries from 30.7 % to 14.3 % and a
gradual decrease in severe head
injuries from 5.9 % to 3.2 % in the
study period. The proportion of head
injuries and severe head injuries
among children wearing helmets and
children not wearing helmets were
13.9 % vs. 26.6 % and 2.8 % vs. 4.5
%. In the study period the proportion of
facial injuries, bone fractures,
spine/columna injuries, and deep
injuries in thorax/abdomen remained
unchanged. Eighteen children died
from their injuries. All had severe head
injuries and none of them wore a
helmet.
Conclusions: The proportion of head injuries from
bicycle accidents among children has
been reduced by about 50 % over the
last decades concurrent with increase
in helmet use. None of the 18
deceased children wore a helmet.
60. Congenital Clubfoot treated by the Ponseti method. Evaluated by the CAP at age 4.
Vilhelm Engell, Niels Wisbech Pedersen, Bjarne Lundgaard, Søren Overgaard
Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Denmark.
Background: Despite the advances in the treatment of
clubfoot, with the advance of The
Ponseti method, there is still no widely
accepted method to evaluate the
outcome. The Clubfoot Assessment
Protocol (CAP) was developed for
follow-up of children treated for
congenital clubfoot. It is a
comprehensive standardized
measurement instrument to evaluate the
clubfoot with respect to mobility, muscle
function, morphology and motion.
Purpose / Aim of Study: The aim of this study is to report our
results of the Ponseti method evaluated
with CAP at age 4 years.
Materials and Methods: In this consecutive prospective cohort
series we included all 44 children
referred to the department with
congenital idiopathic clubfoot from
October 2006 to January 2009. A total of
44 children, with 67 clubfeet were
treated. We excluded 1 patient since the
clubfeet were part of Athrogryposis
Multiplex Congenita, since the treatment
and also the clubfoot is different from
the idiopathic cases. A total of 9 patients
were lost for follow-up. So, 34 children
(77%) with 52 CTEV were our study
population. However, only a total of 28
patients were CAP-scored. Two
children were excluded because they
couldn’t cooperate due to mental
retardation and 4 children didn’t want to
participate.
Findings / Results: The Clubfeet scores lower than the
normal feet in all CAP subgroups. This is
statistically significant in CAP1 Passive
mobility, CAP2 Muscle function and
CAP5 Motion quality II not so in CAP3
Morphology and CAP4 Motion quality I.
We found differences with the clubfeet
scoring lower in Dorsiflexion at the
ankle, Muscle function of M. Peroneus
and Hop on one leg.
Conclusions: The CAP is a comprehensive tool for
follow-up of clubfeet. In this study 3
parameters shoved differences
between normal and clubfeet at age 4
years (ankel dorsiflexion, peroneal
function and one leg jump).