Session 6: Poster med foredrag III

Jonas Hedegaard Andersen, Klaus Kirketerp, Anne Rasmussen
Ortopædkirurgisk afdeling, Hospitalerne i Nordsjælland Hillerød Hospital; Dermato-Venerologisk Afdeling og Videncenter for Sårheling, Bispebjerg Hospital; Steno Diabetis Center, Steno Diabetis Center


Background: Diabetic foot ulcer is a costly complication, prevention and prompt treatment is important to reduce the risk of infection, minor and major amputations.
Purpose / Aim of Study: The aim of the study was to examine the effectiveness of a modified minimally invasive flexor tenotomy technique performed with needle, to prevent and heal toe ulcers in diabetic patient with claw, hammer and mallet toe deformities, seen in our multidisciplinary outpatient clinic.
Materials and Methods: Patients referred from podiatrist to orthopedic surgeon between 17 Th Feb. 2015 and 23 Th Feb. 2016 that underwent percutaneous needle tenotomy of the deep and superficial flexor tendons of the toes. The surgical procedure was performed in local anesthetics. The tenotomy was Performed with a needle, with a diameter of 1,2 mm, and length of 40mm. The needle was introduced through the skin immediately proximal to the web level, in the toe chosen for tenotomy, corresponding to the placement of the deep and superficial flexor tendons. All patients were offered therapeutic sandals and seen at 2 and 7 days post intervention.
Findings / Results: 42 patients had 135 toes treated by percutaneous tenotomy, 16(12%) toes with ulcers and 119(88%) toes with impending ulcerations were treated. Average age was 66.02 years (41-89 years), 30 (71%) were males, average diabetes duration was 24,69 years (6-70 years), 28 patients had type 2 diabetes (66,6%), average BMI were 29,9 kg/m2 (18,9-41,6 kg/m2), HbA1c 63,23 mmol/mol (33-96 mmol/mol), total cholesterol 4,7 mmol/L (1,4-9,4 mmol/L) and blood pressure 135/75 mmHg (97- 200/56-96 mmHg), 4 patients were smokers (10%). Total loss of vibration sense (>50 volt) was observed in 57% off right and 55% of left feet, palpable foot pulses were found on right foot in 36 patients (86%) and 38 on left foot (90%). Retinopathy was present in 5 patients (12%). Ualbcrea ratio was 92,4 (3-920) All surgical incisions healed uneventfully, 41 patients after 2 days (98%), and one patient after 7 days (2%). No complications, e.g. bleeding or pain were recorded. There were 12 neuropathic (75%), 3 neuro-ischemic (19%) and 1 ischemic ulcer (6%). The average duration of ulcer before tenotomi was 6,5 weeks (1- 26 weeks), all ulcers (16) healed in the observation period, in a mean of 24 days (2-105 days). There was no recurrence of toe ulcer in the period. No infection was recorded and no amputations performed due to the procedure. Eight patients had transfer complication (19%), with a total of 12 toes affected. 4 toes had transfer ulcers (33%), and 8 incurred pressure signs (67%) after the primary tenotomy. One patient underwent re-tenotomy due to insufficient primary procedure (2%). Mostly the tenotomy was performed on right foot 90 toes (67%). The tenotomies performed were distributed on: first toe 22 (17%), second toe 37 (27%), third toe 34 (25%), fourth toe 23 (17%) and fifth toe 19 (14%). 6 patients (14%) needed assistance from home nurse to change the dressing or wound observation after the procedure. 28 patients (67%) were treated with handmade shoes with rocker bottom to prevent future ulcers.
Conclusions: Needle tenotomy is a simple, safe and effective procedure for preventing and/or treating ulcers of claw, mallet and hammertoe deformities in diabetic patients. This off-loading surgery should be offered all patients at-risk of ulcers of a hammer, mallet or claw toe. The procedure can result in transfer ulcers if not performed on all toes of one foot at same primary intervention. Flexor tendon tenotomy of the first toe can present a challenge, likely due to the caliber of the tendons, and relation to the sesamoids. The follow-up period was relatively short, and further investigation is needed, and will be carried out at our center.

Simon Damgaard Petersen, Ellen Hamborg-Petersen
Ortopædkir. afd. , Kolding Sygehus; Fod/ankel, Ortopædkir. afd, Odense Universitets Hospital


Background: Accessory ossicles is a frequent development variant. Os talus secundarius(OTS) is a rare accessory ossicle located on the lateral side of the talus, with a prevalence of 0,1%.
Purpose / Aim of Study: In current litterature only 5 cases of OTS with symptomatic problems has been described. Only 3 prior cases with surgical removal dating back from 1972 and 1953.
Materials and Methods: 2 cases including diagnostics, excision and follow-up 6 months after surgery. MRI done pre-surgery and at follow-up after 6 months.
Findings / Results: Two patients, male 29 and 48, presented with pain in the ankle more than 6 months. No former trauma. One felt instability and a feeling of walking on the outside of the foot. The other primarily pain lateral and unable to work. MRI and X-rays showed OTS and adjacent edema. Surgical removal was performed in both cases. One showed OTS with synchondrosis toward the calcaneus and synostosis toward the talus at the sinus tarsi. Tightening of lig. calcanofibulare and lig. talofibulare ant. was performed. Post operative static walker was used for 6 weeks with full weight bearing. The other had an OTS of approximately 1.5 x 1.5 cm with clear osteoarthritis at the articular surface against the talus, and no articulation to the calcaneus or fibula. Lig. talofibulare ant. and lig. calcanofibulare unaffected. Postoperative use of static walker, with weight bearing, for 2 months. After 6 months both patients experienced significant less pain and no complaints of instability. MRI showed regression of edema in adjacent bones and diminished intraarticular fluid.
Conclusions: Accessory ossicles in the foot are not only important in relation to differentiation from normal anatomy when interpreting radiographs, but they may also in themselves give rise to various problems, such as impingement, synovitis and degenerative conditions.

Mazaher Azizpour, Rebekka Fonnesbæk, Kristian Behrndtz, Jorgen Baas
Ortopædkirurgisk Afdeling , Hospitalsenheden Horsens (HEH); , Aarhus University; Ortopædkirurgisk afdeling, Hospitalsenheden Horsens ; Ortopædkirurgisk Afdeling E, AUH


Background: The best treatment of acute Achilles tendon rupture remains unclear. Even within non- operative treatment regimes, it remains uncertain when mobilization and weight- bearing can be instituted without increased risk of rerupture.
Purpose / Aim of Study: In the present retrospective cohort study, two non-operative treatment regimens were compared in terms of rerupture risk
Materials and Methods: Between 2008 and 2014 the standard treatment protocol at Horsens Regional Hospital in Denmark for an acute Achilles tendon rupture was nonoperative. February 1st 2012, this protocol was changed from Treatment A (non-weightbearing equinus cast for the first three of 8 weeks) to Treatment B (non-weightbearing equinus boot for the first two of 8 weeks). The treatment protocols were otherwise mainly alike. From the diagnostic coding of Achilles tendon rupture and surgical coding in the digital patient records, the patients with an acute Achilles tendon rupture/rerupture and their treatment were identified. Based on the time of diagnosis, the Relative Risk for rerupture was calculated for the two different treatment protocols A and B.
Findings / Results: Between 2008 and 2014, 389 patients were registered with an acute Achilles tendon rupture at Horsens Regional Hospital. Treatment A was given to 183 patients from 2008-2012. Treatment B was given to 179 patients from 2012-2014. Twenty-seven patients opted for primary surgery (Treatment C). Treatment A had 1 rerupture and 1 tendon malunion versus Treatment B with 8 reruptures and 2 tendon malunions (RR=4,9, p=0,039), most of which were treated with secondary surgical reconstruction. Treatment group C had 0 reruptures and 0 tendon malunions.
Conclusions: Aggressive early mobilization and weight- bearing in non-operative treatment of acute Achilles tendon rupture may increase the risk of Achilles tendon rerupture.

Roland Knudsen, Frank Damborg, Julie Ladeby Erichsen, Zafar Bahadirov
Department of Orthopedic Surgery, Odense University Hospital; Department of Orthopedic Surgery, Kolding Hospital; Department of Orthopedic Surgery, Kolding Hospital; Department of Orthopedic Surgery, Kolding Hospital


Background: Recent studies have shown a complication rate between 8-27% when treating Dislocated Distal Radius Fractures (DDRF) using Open Reduction and Internal Fixation (ORIF) and a volar plate. This kind of osteosynthesis is a relatively new treatment and initiatives must be identified and implemented to reduce this rate of complications.
Purpose / Aim of Study: We wanted to investigate whether the complication rate changed over time between the period 2008 to 2010 and 2013 to July 2014 at a single institution.
Materials and Methods: We compared two cohorts of patients, who had their DDRF treated with volar plating at the same institution in the above-mentioned periods. There were two differences between the two cohorts: in the latter period more operations were supervised and the surgeons had gained more experience in the latter period. The possible complications were: carpal tunnel syndrome, tendon irritation/rupture, insufficient osteosynthesis, reduced ROM, infection, complex regional pain syndrome and skin healing problems. The complications were only registered as a complication if an intervention was deemed necessary.
Findings / Results: 88% of the operations in the last group were performed or supervised by a qualified orthopaedic surgeon versus 79% in the first group (p < 0,01). The overall complication rate was reduced from 18% to 13% (p<0,01). The rate of two kinds of complications was reduced significantly: Tendon irritation/rupture was reduced from 5% to 1% (p=0,02) and insufficient osteosynthesis rate was reduced from 7% to 2% (p<0,01).
Conclusions: The overall complication rate was reduced significantly from 18 to 13%. We believe, the reduction of complications is mainly because of increased supervision and because the qualified orthopaedic surgeons became more familiar with this procedure.

Ole Brink
Orttopaedic Surgery - Traumatology, Aarhus University Hospital


Background: Intramedullary nailing of the tibia using a suprapatellar approach (SPI) has become more popular in the past years. Advantages of the technique is easier nailing of the proximal and distal fractures and easier positioning of the patient. Few studies have yet evaluated the outcome.
Purpose / Aim of Study: The aim of this prospective study was to evaluate the operative experience, clinical and patient’s subjective outcome following SPI nailing.
Materials and Methods: Forty-five consecutive patient with tibia fractures and treated with SPI nailing using were included. Eight patient were admitted as poly-trauma, and five patients were habitual mobilized in wheelchair. After a minimum follow-up of 1 year all alive patients were asked to complete a questionnaire. Lysholm score, EQ-5D and VAS pain score were used to evaluate functional outcome and health status.
Findings / Results: Twenty-eight patients were treated with Trigen Tibial Nail (Smith & Nephew) and 17 with T2 Tibial Nail (Stryker). Patients average age was 55 (range: 17-91). Seven fractures were OTA-AO type A, 32 type B and 6 type C. Ten fractures were open, including 4 Gustilo grade III. Mean operating time was 100 minutes (range: 28-295). There were no intraoperative complications. One patient in anticoagulant therapy developed haemarthrosis postoperatively. One fracture had delayed union and healed after change of locking screws. Four patients died before follow-up and among 41 eligble 25 completed the questionnaire with a mean followup time of 749 days. Average pain analogue score while walking (if walking) was 3.18, Lysholm score = 69 (CI: 59-78) and EQ-5D = 60 (CI: 49-72).
Conclusions: In this heterogen population the results indicate that SPI is a useful and safe procedure for treating tibial fractures, and patient outcome is comparable to studies evaluating infrapatellar nailing.

Signe Hulsbæk, Rikke Faebo Larsen, Morten Tange Kristensen
Department of Occupational Therapy and Physiotherapy, Zealand University Hospital; Department of Occupational Therapy and Physiotherapy, Zealand University Hospital; Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Departments of Physical Therapy and Orthopedic Surgery, Copenhagen University Hospital Hvidovre


Background: An increasing number of settings organize their treatment of acute hip fracture patients (HF) in orthogeriatric or geriatric units. This means that e.g. data of functional capacity of HF patients is reported to the Danish hip fracture database using the Cumulated Ambulation Score (CAS), but also to the corresponding Danish database of geriatrics using the Barthel-100 and 30-s Chair- Stand-Test (CST). Further, a new score for assessing mobility; de Morton Mobility Index (DEMMI) was recently added to the geriatric database and thereby also used for patients with acute HF, although not validated in that context.
Purpose / Aim of Study: To examine the validity of DEMMI in patients with HF in comparison with the existing Barthel-100, CST and CAS.
Materials and Methods: 222 consecutive patients (57 nursing home residents) with HF admitted to a Geriatric Department following surgery were assessed with the 4 measurements on day 1 and at discharge (mean LOS post-surgery 9 days (SD 5.1)).
Findings / Results: 98% and 89% of patients were not able to perform the CST at baseline and at discharge (large floor effect), respectively. Corresponding floor effects were 39% and 31% for DEMMI, 12% and 5% for Barthel-100, and 22% and 6%, respectively for CAS. Convergent validity was strong between DEMMI and CAS (r=0.76, 95% CI 0.69-0.81), and moderate between DEMMI and Barthel (r=0.58, 95% CI 0.48- 0.66). Responsiveness, as indicated by the Effect Size was 0.76 for DEMMI, 1.78 for Barthel-100 and 1.04 for CAS. Baseline scores of DEMMI, Barthel and CAS showed similar properties in predicting discharge destination of patients from own home.
Conclusions: Dealing with 4 outcome measures in short hospital stays is time-consuming. The value of using DEMMI and CST in patients with acute HF seems limited in comparison with Barthel-100 and CAS, and therefore should be re-evaluated.

Spogmai Zadran, Jens Olesen, Sten Rasmussen
Orthopaedic Surgery, Aalborg University Hospital; Orthopaedic Surgery, Aalborg University Hospital; Orthopaedic Surgery, Aalborg University Hospital


Background: The acute lateral ankle sprain accounts for 85% of all sprains. The lateral sprain associated with other ligament injuries, such as medial and syndesmosis sprain. In the long-term approximately 20% of the acute lateral sprain develops chronic lateral ankle instability (CLAI). The definition of the chronic ankle instability is persistent pains, repeatedly ankle sprains and episodes of ankle giving away.
Purpose / Aim of Study: The aim of this study was to correlate the clinical examination to ultrasonography (US) after ankle sprain.
Materials and Methods: Through 15 october to 26 november 2016 patients who were diagnosed with an ankle sprain were included. We evaluated with high frequency (15-6 MHz) ultrasonography the lateral ligament injury (anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), syndesmosis (anterior intertibiofibular ligament (AiTFL)) injury) and medial ligament injury (deep posterior tibiotalar ligament (dPTL), tibiocalcaneal ligament (TCL)).
Findings / Results: 16 women and 10 men and the mean age was 26.7 years, and the mean BMI was 26.6 (17.2-41.3) participated. Two clinical signs statistically correlated with US and multiple logistic regression analysis confirmed the results. The US confirmed ATFL partial rupture and normal CFL. Positive palpated tenderness AiTFL predicted with partial ruptured ATFL and secondly reported pain during active plantar flexion of ankle predicted with normal confirmed US CFL.
Conclusions: The study predicted patients with partial rupture of ATFL clinical present with tenderness at AiTFL point and patients presented with intact CFL reported pain during active plantar flexion. The overall clinical signs and physical examinations were unreliable factors to predicate lateral (ATFL, CFL), syndesmosis injuries (AiTFL) and medial ligament injuries compared with the US findings.

Charlotte Packroff Stenqvist, Naja Bjørslev, Susanne van der Mark
Department of Orthopaedic Surgery , Bispebjerg University Hospital of Copenhagen; Department of Orthopaedic Surgery , Bispebjerg University Hospital of Copenhagen; Department of Orthopaedic Surgery , Bispebjerg University Hospital of Copenhagen


Background: Early surgery has been shown to be associated with lower mortality and complication rates in patients experiencing a hip fracture. New Oral AntiCoagulants (NOACs) have been approved since 2008; 20% of Danish patients receiving antithrombotics medicate with NOACs. NOACs are prescribed to prevent thrombo- embolic events in patients with atrial fibrillation and as prophylaxis after surgery. The rising consumption of NOACs is an increasing problem for trauma surgeons due to a half-life of 7-17 hours with normal renal function and increasing risk of uncontrolled bleeding. NOAC treatment can lead to postponement of acute surgery.
Purpose / Aim of Study: The aim of this study is to analyse the percentage of hip fracture patients admitted in 2015, who received NOACs or other antithrombotics, and if surgery was delayed due to NOACs.
Materials and Methods: Chart review from 1 January 2015-31 December 2015, using ICD-10 codes DS72.0-DS72.2. We excluded re- operations, periprosthetic fractures and contralateral hip fracture within the same year.
Findings / Results: We found 451 patients admitted with a hip fracture, 435 were included. 185 (42.5%) patients received antithrombotic treatment. 44.7% were treated with acetylsalicylic acid, 24.4% with Clopidogrel, 12.7% received Vitamin K-antagonist and 4.1% Adenosine re-uptake inhibitor. 27 patients (13.7%) were treated with NOACs. Nine received Dabigatran, 11 Rivaroxaban and seven Apixaban. In 24 of 27 patients receiving NOACs, surgery was delayed 1-3 days because of NOAC treatment. During 2015, 6.2 % of all hip fracture patients in our department received NOACs. Surgery was postponed in 89 % of these patients.
Conclusions: We see an increasing consumption of NOACs in Denmark, our data reveals the necessity that orthopedic surgeons are professionally updated on perioperative complications associated with NOAC treatment.

Linea Holck Lundholm, Kim Hegnet Andersen, Jeannette Østergaard Penny
Faculty of Health and Medical Sciences, stud.med., University of Copenhagen; Department of Orthopedic Surgery, Hvidovre Hospital; Department of Orthopedic Surgery, Hvidovre Hospital


Background: Recently the algorithms for treating primary closed Achilles tendon ruptures (ATR) have drifted towards non operative treatment. After subacute foot and ankle surgery was appointed to one person, he noted more re- ruptures than expected.
Purpose / Aim of Study: Our primary aim was to investigate the re- rupture rate of conservatively treated ATR in the year since the treatment was referred to a dedicated foot and ankle surgeon (year A), to describe the reconstructions and patient demographics. Secondary aims were to compare it to the previous year (B), and if any difference was found, to investigate if a difference was to be found in the treatment algorithms or demographics.
Materials and Methods: A search on DS860 and DT935B was performed on ER and outpatients. Age, sex, primary treatment, re-ruptures and type of reconstructions was registered. Summary statistics and 2 group proportion tests used.
Findings / Results: We treated 107 true ATR in year B. Of those, 3 had an open rupture, 34 were not primarily treated at HVH and 3 had primary surgery. In year A, 133 had ATR, 39 not primarily treated at HVH and 2 had primary surgery. Leaving 67 and 92 for analysis (78% men/ 22% women, mean age 46 ). No difference between A and B. Weight bearing details on conservative treatment were lacking. In year B, 2 patients had a re-rupture following conservative treatment, corresponding to 3% and 12 patients in year A=13% which was significant with p=0.03. The re-rupture surgery needed 6 elongations, 1 flex hall transfers, 4 vendebro plasties.
Conclusions: We found re-rupture rates in line with the literature but higher in year A. Comparable patient demographics but conservative regime will require further investigation to explain the increased re-rupture rate. Generally re-rupture surgery required more extensive surgical interventions than an end-to-end.