Session 11: Sport Orthopaedics

Anders Ploug Boesen
Sports Orthopedic Research Center- Copenhagen (SORC-C), Artroskopisk center, Ortopædkirurgisk afdeling, Amager- Hvidovre Hospital


Background: High-Volume Injection therapy (HVI) seems to show promising results in chronic Achilles tendinopathy (AT). HVI consist of a large volume of saline with a small amount of cortisone.
Purpose / Aim of Study: To determine the effect of cortisone in HVI compared to the volume (saline) effect in AT.
Materials and Methods: A total of 28 men (age, 18 to 59 years) with chronic (> 3 month) AT were included and followed for 6 month. All participants performed eccentric training and randomized to either 1) HVI injection with cortisone (HVI+: cortisone, saline and local anesthetic) or 2) HVI injection without cortisone (HVI%: saline and local anesthetic). Outcomes included function and symptoms (VISA-A), self-reported tendon pain during activity (visual analog pain scale [VAS]) and ultrasonographic imaging (tendon thickness and intra- tendinous vascularity). Outcomes were assessed at baseline and at 6, 12, and 24 weeks of follow-up.
Findings / Results: VISA-A scores improved in both groups at all time points (p<0.05), with greater improvement in HVI+ (mean ± SEM; 6- wks=31 ± 3 points; 12-wks=32 ± 5 points) versus HVI% (6-wks=14 ± 3; 12-wks=18 ± 3;) at 6 and 12 weeks (p<0.05) but with no differences at 24 weeks (HVI+ = 26 ± 3; HVI% = 24 ± 3). VAS scores improved in both groups at all time points (p<0.05), with greater decrease in HVI+ (6-wks= 55 ± 3 mm; 12-wks= 53 ± 5 mm) versus HVI% (6- wks=16 ± 3 mm; 12-wks=25 ± 5 mm) at 6 and 12 weeks (p<0.05) but with no differences after 24 weeks (HVI+ = 40 ± 7 mm vs HVI% = 34 ± 6). Tendon thickness showed a significant decrease in both groups at all time-points (p<0.05), with a greater decrease in HVI+ versus HVI% at 6 and 12 weeks (p<0.05) but with no difference at 24 weeks.
Conclusions: Treatment with HVI with or without cortisone in combination with eccentric training in chronic AT seems effective in reducing pain, improving activity level and reducing ultrasound tendon thickness and intra- tendinous vascularity. HVI with cortisone seemed more effective than without cortisone in the short term, and we argue that there is a cortisone effect in HVI treatment.

Morten Lykke Olesen, Bjørn Borsøe Christensen, Casper Bindzus Foldager, Kris Chadwick Hede, Natasja Leth Jørgensen, Martin Lind
Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Aarhus University Hospital; Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Aarhus University Hospital; Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Aarhus University Hospital; Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Aarhus University Hospital; Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Aarhus University Hospital; Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Aarhus University Hospital


Background: Microfracture (MFx) remains a dominant treatment strategy for symptomatic articular cartilage defects. Autologous platelet-rich plasma (PRP), may improve biological cartilage repair as an adjunct to MFx.
Purpose / Aim of Study: To assess the histological quality of cartilage repair after MFx with and without repeated local injections of PRP for the treatment of full-thickness focal chondral defects of the knee.
Materials and Methods: Two full-thickness chondral defects (Ø = 6 mm) were surgically performed in the medial and lateral trochlea of each knee in six skeletally mature Göttingen minipigs. The two treatment groups were 1) MFx with one weekly PRP injection for three weeks (n=12), and 2) MFx alone (n=12). The animals were euthanized after six months. Samples of both whole blood and PRP were analysed with an automated hematology analyzer to determine the concentrations of platelets and nucleated cells. The composition of cartilage repair tissue was assessed using gross appearance as-sessment, histomorphometry and semi-quantitative scoring (ICRS II).
Findings / Results: The average fold increase in platelets was 6.2 ± 1.3. Leukocyte concentration decreased in PRP samples by an average fold change of 1.5 ± 0.1. Our macroscopic findings showed that the defects in the MFx+PRP-treated group, were filled with an irregular, partially rough tissue similar to the MFx- treated group. No significant difference in hyalin cartilage, fibrocartilage or fibrous tissue content and ICRS II scores was found between the groups.
Conclusions: Four repeated local injections of leukocyte-reduced PRP after MFx in the treatment of full-thickness cartilage injuries demonstrated no beneficial effects in terms of macroscopic and histological cartilage repair tissue quality.

Niclas Højgaard Eysturoy , Torsten Grønbech Nielsen, Martin Carøe Lind
Division of SportsTrauma, Department of Orthopaedic Surgery., Aarhus University Hospital, Aarhus.; Division of SportsTrauma, Department of Orthopaedic Surgery., Aarhus University Hospital, Aarhus.; Division of SportsTrauma, Department of Orthopaedic Surgery., Aarhus University Hospital, Aarhus.


Background: Registry studies have suggested increased revision rates and inferior clinical outcomes when using the newer anteromedial (AM) technique for femoral drill hole placement compared to the more established transtibial (TT) technique in primary anterior cruciate ligament reconstruction (ALC-R).
Purpose / Aim of Study: The aim of this study is to compare the techniques from two different time-periods, namely the period when the AM-technique was initiated and a more recent period when it has been established as a common technique.
Materials and Methods: Respectively 8.436 and 8.862 primary ACL- R were registered in the Danish Knee Ligament Reconstruction (DKRR) between January 2007 to December 2010 and January 2012 to December 2015. Relative risk (RR) for revision ACL-R, positive pivot- shift, increased instability (KT-1000 > 2mm) and patient-reported outcome was used to compare the outcome of the two periods.
Findings / Results: The AM-technique went from being used in 23% in 2007-10 to 84% in 2012-15. The relative risk (RR) for revision surgery in the AM (2007-10) cohort compared to TT (2007-10) cohort was 1.55 (P < 0.00). Comparing AM (2012-15) to TT (2012-15), no difference was found. In the 2007-10 period, the one-year postoperative RR for positive pivot-test was 1.28 (P<0.00), and for instability was 1.45 (P<0.00), both in favour for the TT- technique. There was no significant difference in the period from 2012-15
Conclusions: We found an increased RR of revision ACL- R, increased rotational and sagittal instability when using the AM technique in the period from 2007-10 compared to the TT technique. However, there was no significant difference between the techniques in the period from 2012-2015. This could indicate that the results found in the period 2007-10 may have been caused by a learning curve when introducing a new and more complex procedure (AM)

Erik Poulsen, Glaucia H. Goncalves, Ewa M. Roos, Jonas B. Thorlund, Carsten B. Juhl
Department of Sports Science and Clinical Biomechanics, University of Southern Denmark; Department of Physical Therapy, Federal University of Sao Carlos, Brazil; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark; Department of Rehabilitation, Copenhagen University Hospital, Herlev and Gentofte


Background: Knee injury is reported as an osteoarthritis (OA) risk factor.
Purpose / Aim of Study: To quantify the risk of knee OA following anterior cruciate ligament (ACL) injury, meniscal injury or combined ACL and meniscus injury.
Materials and Methods: Five major databases were searched up to April 1st 2015 and references from included studies and relevant systematic reviews were screened. Two authors independently screened and assessed identified studies for eligibility. Inclusion criteria: prospective or retrospective studies, ≥ 2-year follow- up after knee injury, ≥ 18 years, un- injured contralateral knee or matched control group for comparison, knee OA defined by radiographs or symptoms. Risk of bias were assessed by the SIGN50 tool. Meta-analysis applied based on the logarithmic transformed Odds Ratio (OR) of developing knee osteoarthritis. Study heterogeneity were assessed by I-square statistics. Study registration: PROSPERO (ID: CRD42015016900).
Findings / Results: A total of 4559 papers were identified in the search, 261 full-text were screened and 46 papers included. Knee OA diagnosis was based on radiographs in 96% of studies. For ACL injury, 12 studies were included (185.276 participants, mean age 28.0, 35% females), OR for developing knee OA was 4.2 (95% CI: 2.4-7.6). Meniscal injury, 20 studies (6.211 participants, mean age 33.0, 23% females), OR 5.8 (95% CI: 3.9-8.6). Combined injury, 18 studies (1295 participants, mean age 25.5, 32% females), OR 7.0 (95% CI: 4.8-10.4). Inconsistency between study estimates for different injury types were between 57-91%. Risk of bias assessment rated two studies of high quality, 43 acceptable, and one study unacceptable.
Conclusions: The risk of OA development following an ACL or a meniscal injury is 4 and 6 times higher compared to a non-injured knee. When sustaining a combined injury, the risk is 7-fold.

Peter Faunø, Torsten Nielsen, Martin Lind
Dept Sports Medicine, Aarhus University Hospital; Dept Sports Medicine, Aarhus University Hospital; Dept Sports Medicine, Aarhus University Hospital


Background: Concern about growth disturbances around the knee after traditional ACL reconstruction in the skeletal immature patient has led to interest in physeal sparing ACL reconstruction techniques. There is limited data that describe clinical results with these techniques.
Purpose / Aim of Study: The purpose of the study was to describe the short-term subjective and objective outcome after physeal sparing ACL reconstruction technique in skeletal immature patients.
Materials and Methods: Until December 2015, 57 skeletal immature patients underwent a physeal sparing ACL reconstruction using quadrupled Semitendinosus autograft using the Flipcutter drilling system (Arhtrex) for the preparation of bone sockets and Tightrope (Arthrex) as both femoral and tibial fixation. The patients had a mean age at 13,5 (11-15) and were assessed preoperatively and one year postoperatively using KT1000, manually pivotshift testing and PEDI-IKDC. The results were compared to a comparable cohort of patients (N=42) operated from 2001-2010 with a transphyseal technique using femoral endobutton fixation and tibial extracortical fixation with washer and bicortical screw.
Findings / Results: In the physeal sparing group the properative KT-1000 laxity was improved from 4,6 to 1,6mm. In the historical group from 5,2 to 1,1 mm. (NS). We found pivot-shift more than grade 1 one year after surgery in 2/57 patients compared to 0/42 the historical group (NS). The mean PEDI IKDC was after one year 86,6 (53-100) compared to IKDC in the historical group 78,6. (NS)
Conclusions: We found good results after one year with physeal sparing ACL reconstruction technique, but with no difference compared to a transphyseal technique. However, we describe early results and longer observation and growth disturbance evaluation is needed to validate the future role of the physeal sparing technique in ACL reconstruction in skeletal immature patients.

Anders Holsgaard-Larsen, Jonas B Thorlund, Tim Blackmore, Mark W Creaby
Orthopaedic Research Unit, Department of Orthopaedics and Traumatology, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark; School of Exercise Science, Australian Catholic University, Brisbane, Queensland, Australia; School of Exercise Science, Australian Catholic University, Brisbane, Queensland, Australia


Background: The total lower limb support moment (TSM), is the sum of positive sagittal plane moments at the hip, knee and ankle, and is required to support body mass during gait and may be altered following arthroscopic partial meniscectomy (APM).
Purpose / Aim of Study: To test the hypothesis that a) individuals prior to surgery demonstrate reduced TSM and relatively higher distribution of ankle and hip moments as a potential strategy to spare/unload the injured knee and b) following surgery TSM outcome measures of the injured leg will be closer to the contralateral leg.
Materials and Methods: Individuals with a medial degenerative meniscal tear eligible for APM were recruited. To estimate changes in peak TSM, and positive ankle (ASM), knee (KSM), and hip (HSM) moments, 3D motion analysis of walking at self- selected speed prior to APM and 12 months after APM was performed.
Findings / Results: Patients (n = 21) were middle aged (age: 45.9 ± 6.3 years), slightly overweight (BMI: 25.9 ± 3.6 kg/m2) and the majority male (71%). At baseline a statistically significant lower KSM (30%, P = 0.048) and a tendency towards a lower peak TSM (9%, P = 0.099) were observed for the APM compared with the contra-lateral leg. Following surgery a more equal distribution of support moment variables were observed since a statistically significant between-leg change (baseline versus 12 months follow-up) for peak TSM (mean [95% CI]; -0.49 [-0.96; -0.01], P = 0.047) was observed.
Conclusions: Individuals prior to APM demonstrated a potential strategy to spare/unload the injured knee. The observed differences were not present at 12 months post- APM. Whether these changes in TSM strategy should be considered a normalization towards a ‘healthy joint load distribution’ or a contributor to the high risk of knee OA development in patients undergoing APM needs to be established.

Jens-Christian Beuke, Jens Christian Pörneki, Jesper Vinther, Niels Maagaard, Bjarke Viberg
Department of Orthopaedic Surgery and Traumatology, Kolding Hospital – part of Lillebælt Hospital ; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital – part of Lillebælt Hospital ; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital ; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital ; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital – part of Lillebælt Hospital


Background: In surgical treatment of lateral patellar instability, the reconstruction of the medial patellofemoral ligament (MPFL) has become a gold standard to re-establish the medial soft tissue’s strength in restraining lateral patella displacement.
Purpose / Aim of Study: The study investigates the outcomes of a novel operative method for non-anatomic functional MPFL recon-struction using the medial collateral ligament (MCL) as a pulley.
Materials and Methods: The cohort consisted of 149 patients (160 knees) with lateral patellar instability, who underwent MPFL re-construction with the MCL pulley from 2010 to 2015 at Kolding and Odense. Patient records were reviewed retrospectively and a questionnaire study registered patient answers (n = 104; 69.8 %) for the following patient-reported outcome measures: Kujala and Tegner-Lysholm knee scoring scales, EuroQol EQ-5D-3L, and other relevant aspects. Non-parametric statistics were performed due to non-Gaussian distribution.
Findings / Results: 89.4 % of the 160 knee operations had a postoperative course without problems; for 5.0 % and 5.6 % knees minor or major postoperative complications were found respectively. Medial knee tenderness after 6 weeks was registered for 12.5 % of the knees. With an interquartile range (IQR) of 68-91, the median Kujala score was estimated to 81, whilst the Tegner-Lysholm score was 87 (IQR: 74-94). The EQ-5D-3L showed to be 0.84 (IQR: 0.78-1.0). None of the patients characterised their operation as poor, 3.1 % re-ported it as fair, and 96.1 % had a well to excellent result from their operation. Compared to pre-surgery, 2.5 % described a worse knee outcome. 8.2 % no difference and 89.3 % had a better outcome.
Conclusions: Using the MCL pulley in functional reconstruction of the MPFL seems promising with low rate of complica-tions and little or no medial tenderness after 6 weeks.

Erik Poulsen, Bent Lund, Eleanor Boyle, Ewa M. Roos
Department of Sports Science and Clinical Biomechanics, University of Southern Denmark; Department of Orthopaedic Surgery, Horsens Regional Hospital; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark


Background: The Danish Hip Arthroscopy Registry (DHAR) started in 2012 to assist in quality assurance of hip arthroscopy in public and private hospitals.
Purpose / Aim of Study: To report completeness of patient characteristics and patient reported outcome measures (PROMs).
Materials and Methods: We analyzed completeness of DHAR by comparing it against the Danish National Patient Register (DNPR) and reported the proportion of registrants in DHAR to DNPR. We further determined if a differential follow-up rate occurred by comparing baseline demographics (age and sex), activity level measured by the Hip Sports Activity Scale (HSAS) and PROMs of those who responded to the 1-year follow-up against those who did not. The PROMs were the Copenhagen Hip and Groin Outcome Score (HAGOS) and the International Hip Outcome Tool – short version (iHOT12).
Findings / Results: From February 2012 to February 2016, 3,016 arthroscopic hip surgeries were registered in DHAR and 5,501 in DNPR. The proportion of completed increased from 35% for the first six months to 43, 57, 59, 61 and 68% for the last period. As of June 2017, 1,594/2,059 (77%) had completed 1-year follow-up questionnaires and 158 patients (<1%) had returned 1-year follow-up questionnaires but were not registered in the surgical database. At 1-year follow-up, more males (45 vs. 39%, p = 0.021) and more participating in sports at competitive level (15 vs. 9%, p< 0.001) did not respond. Age, all subscales of HAGOS and the iHOT12 score did not differ between responders and non- responders.
Conclusions: During its first four years, the reporting of arthroscopic surgeries in DHAR had increased from 35 to 68%. One-year follow-up data is available for 77%. More commonly, men participating in competitive sports did not return 1-year follow-up questionnaires.

Niels Christian Kaldau, Stig Brorson, Bent Lund
Orthopedic, Aleris-Hamlet Hospital; Orthopedic, Herlev Hospital; Orthopedic, Aleris-Hamlet Hospital


Background: Short-term outcome after hip arthroscopy for femoroacetabular impingement (FAI) have been reported to be successful. However, mid-term and long-term outcome are sparsely reported.
Purpose / Aim of Study: To report the mid-term patient-reported outcome in a consecutive cohort and to investigate the relationship between cartilage lesions and the conversion rate to total hip arthroplasty (THA).
Materials and Methods: Eighty-four FAI patients with a joint space width of > 3 mm operated by the senior author were retrospectively followed for 6–8 years. The conversion rate to THA, the peri- operative findings and the patient-reported outcome (HAGOS, HSAS, and EQ5D) were assessed
Findings / Results: Fifteen out of 84 (18 %) patients were converted to THA. The 5-year cumulative conversion rate was 17,1 % (CI: 8.5 %; 24.9 %). The THA group was significantly older (p=0.021), with a mean age of 46.7 years (95% CI: 42.8; 50.6) compared to 39.7 years (95% CI: 36.9; 42.4) in the non- conversion group. In the THA group 13 out of 15 patients were 40 years or older (p=0.009). A high-grade acetabular cartilage lesion was associated with a higher risk of conversion to THA. Thirteen out of 15 with Beck grade 3–4 were converted (p=0.015). No significant associations were observed between the peri-operative findings and PROMs in the non-conversion group. Sixty- four patients out of 69 (93 %) were willing to have the arthroscopy performed again.
Conclusions: The mid-term results of arthroscopic hip- preserving surgery show conversion rates to THA of 18 %, high patient satisfaction and good functional outcome. High-grade cartilage lesions and an age of 40 years and older are risk factors for conversion to THA.

Christian Dippmann, Line Dahl, Torsten Warming, Michael Rindom Krogsgaard
Section for Sports Traumatology M51, Department of Orthopedic Surgery, , Bispebjerg Hospital, Denmark ; Department of vascular surgery, National University Hospital, Rigshospitalet, Copenhagen, Denmark; Section for Sports Traumatology M51, Department of Orthopedic Surgery, , Bispebjerg Hospital, Denmark ; Section for Sports Traumatology M51, Department of Orthopedic Surgery, , Bispebjerg Hospital, Denmark


Background: Hip arthroscopy (HA) is indicated for symptomatic intraarticular pathologies of the hip, not related to hip dysplasia, acetabular retroversion or osteoarthritis. Even though the underlying pathologies are different, clinical symptoms are similar, and triaging these patients to the right treatment is therefore challenging
Purpose / Aim of Study: We aimed to evaluate, if a clinical decision algorithm (CDA) for patients with hip pain could change treatment outcome. We hypothesized that the algorithm would allow early and precise triage and thereby a higher precision of correct treatment
Materials and Methods: We implemented a CDA for patient selection in January 2015. 46 consecutive patients undergoing HA with labral repair one year before (group A) and one year after (group B) implementation were evaluated with Copenhagen Hip And Groin Score (HAGOS) before and 3 and 12 months after surgery. Data were analyzed using a two-way repeated- measures ANOVA test
Findings / Results: There were 46 patients (24 males (M), 22 females (F)), average age 35yr (M) and 37yr (F), of which 20 were in group A and 26 in group B. There were no difference in HAGOS score (each domain) between the two groups prior to surgery. Both groups showed significant improvement in all subdomains of the HAGOS 3 and 12 months after surgery. The improvement from 12 to 52 weeks in the domain Physical Activity was significantly higher in group B compared to group A (p<0,00) and near-significant preoperatively to 52 weeks (p=0,052). However, when comparing the other domains, no significant differences could be seen between groups after 12 months
Conclusions: This retrospective case-control study support the hypothesis, that a standardized clinical algorithm for patient selection for hip arthroscopy with labral repair is an advantage for treatment outcome, probably due to better patient selection