Posterudstilling

Cecilie Henkel, Mette Mikkelsen, Alma Bečić Pedersen, Lasse Enkebølle Rasmussen, Kirill Gromov, Andrew Price, Anders Troelsen
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Clinical Epidemiology, Aarhus University Hospital; Department of Orthopaedic Surgery, Vejle Hospital; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, Oxford; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre


Background: The narrow indications for unicompartmental knee arthroplasty (UKA) previously proposed have proven unnecessary, increasing the proportion of patients eligible for UKA to around 50 %. As low surgical volume and UKA-percentage (usage) are associated with higher revision rates, it is of interest whether the changed view on candidacy has affected patient selection for UKA.
Purpose / Aim of Study: Therefore, our aim was to explore changes in patient selection for UKA by assessing: 1) time trends in patient characteristics and 2) whether these are associated with centre UKA- volume and -usage.
Materials and Methods: We included patients from the Danish Knee Arthroplasty Registry with primary medial UKAs performed for primary osteoarthritis in 2002-2016 (n=8.501). We explored trends in sex distribution, age, weight, and American Knee Society Score (knee and function scores) as registered preoperatively. Using locally weighted regression, we assessed whether the trends varied with centre volume (< 52 versus ≥ 52 UKAs per year) and usage (UKAs < 20 % versus ≥ 20 % of primary arthroplasties).
Findings / Results: Overall, we found a decreasing proportion of females, an increasing trend for age and weight, and a bell-shaped trend for knee and function scores, both decreasing throughout the last 10 years. Patients from low-usage centres were more often female, were younger, weighed less, and had better knee scores; though for age and knee score, the groups were converging since 2011. The corresponding patterns for centre volume were largely analogous.
Conclusions: Characteristics of UKA-patients have changed in the last 15 years irrespective of centre volume and usage. There were between-group differences with respect to both volume and usage, though with convergence in trends for age and knee score, suggesting an increasingly uniform approach to patient selection.

Daan Koppens, Ole Gade Sørensen, Stig Munk, Jesper Dalsgaard, Søren Rytter, Solveig Kärk Abildtrup Larsen , Maiken Stilling, Torben Bæk Hansen
Orthopedic Department, Regional Hospital of Holstebro; Orthopedic Department, Aarhus University Hospital; Orthopedic Department, Regional Hospital of Holstebro; Orthopedic Department, Regional Hospital of Holstebro; Orthopedic Department, Regional Hospital of Holstebro; Radiology Department, Regional Hospital of Holstebro; Orthopedic Department, Regional Hospital of Holstebro; Orthopedic Department, Regional Hospital of Holstebro


Background: Patient selection is important for a good clinical outcome after medial unicompartmental knee arthroplasty (UKA), and importantly, lateral compartment osteoarthritis (OA) must be excluded.
Purpose / Aim of Study: To examine the reliability of valgus stress radiographs with the Telos stress device for assessment of lateral compartment degenerative changes in patients with medial osteoarthritis of the knee.
Materials and Methods: A prospective reliability study was performed. Seventy-nine patients (80 knees) were included, and standardised valgus stress radiographs were obtained using the Telos stress device. Osteophytes and joint space narrowing (JSN) were graded using the OARSI atlas, and the joint space width (JSW) was measured in millimetres. Intra-and inter-rater reliability and test-retest reliability were determined. Weighted kappa was used to determine the reliability of osteophyte and JSN grading, and the intra-class correlation coefficient was used for JSW.
Findings / Results: Grading of osteophytes had an intra- and inter-rater reliability ranging from 0.40 to 0.83 on the medial side, and from 0.39 to 0.87 on the lateral side. Grading of medial JSN had an intra- and inter-rater reliability ranging from 0.62 to 0.84, and grading of lateral JSN had an intra- and inter-rater reliability ranging from 0.32 to 0.65. Intra- and inter-rater reliability of JSW ranged from 0.84 to 0.98 on the medial side, and from 0.59 to 0.89 on the lateral side. Test-retest reliability of JSW of the medial and lateral side ranged from 0.69 to 0.92.
Conclusions: Evaluation of the lateral compartment on valgus stress radiographs is most reliable with measurement of the lateral JSW. Standardised valgus stress radiographs taken with the Telos stress device are a reliable supplement in the clinical evaluation of patients with medial OA of the knee.

Kristoffer Lindvig, Rehne Lessmann Hansen
Orthopaedic Surgery Department, Regional Hospital Horsens; Orthopaedic Surgery Department, Regional Hospital Horsens


Background: Recent studies find that vitamin D (vit. D) insufficiency (<50nmol/l) is associated with adverse events after joint replacement surgery such as postoperative infections, joint stiffness and longer hospital stay. Experimental rat studies find that low vit. D concentrations markedly impairs the implant osseointegration. In a general Danish population the prevalence of vit. D insufficiency is reported to be 52.2%. Correction of vit. D insufficiency is cheap; however, vit. D concentration is rarely measured before joint replacement surgery.
Purpose / Aim of Study: The purpose was to estimate the prevalence of vit. D insufficiency in patients undergoing hip or knee arthroplasty.
Materials and Methods: Patients scheduled for uncemented total hip, hybrid total knee or unicompartment knee arthroplasty were consecutively enrolled. Bloodsamples (calcium, parathyroid hormone, vit. D2 and D3) and questionnaires were collected preoperatively and after six months. Follow- up is completed September 2018. Vit. D insufficiency was corrected with oral supplements of calcium (800mg) and vit. D (38µg).
Findings / Results: We included 185 patients with a mean age of 66.3 years (range 36 to 86). Preoperatively 22% (n=40) had vit. D insufficiency and after six months 12% (n=8) had vit. D insufficiency (p= 0.58). Two patients were diagnosed with primary hyperparathyroidism and six had secondary hyperparathyroidism. Patients preoperatively diagnosed with vit. D insufficiency had a significant increase from 35nmol/L (SD= 8.17) to 89.5nmol/L (SD=24.4) (p= 0.001) in vit. D concentration at six months follow-up.
Conclusions: Vit. D insufficiency is present in more than 20% of the patients scheduled for hip or knee arthroplasty and correction should be considered before undertaking joint replacement surgery.

Lone Frandsen, Randi Gram Rasmussen, Torsten Grønbech Nielsen, Martin Lind
Division of Sports Trauma, Department of Orthopedic Surgery, Aarhus University Hospital ; Department of Physiotherapy and Occupational Therapy , Aarhus University Hospital ; Division of Sports Trauma, Department of Orthopedic Surgery, Aarhus University Hospital ; Division of Sports Trauma, Department of Orthopedic Surgery, Aarhus University Hospital


Background: Knee braces for static and dynamic posterior tibial support (PTS) are used in non-operative treatment of acute injury to the posterior cruciate ligament (PCL). Typically, the braces are used for a longer period requiring optimal patient compliance. Patients’ perceptions on possible physical, psychological and social challenges associated with the use of PTS braces have not been described in the existing literature.
Purpose / Aim of Study: To describe patient-reported problems associated with use of either static or a dynamic PTS braces.
Materials and Methods: A prospective and descriptive cohort study of 54 consecutively enrolled patients undergoing non-operative treatment of acute injury to the PCL. Data were collected from a non-validated questionnaire designed on the basis of data from semi- structured patient interviews and including questions on skin disorders, problems with odor, choice of clothes and influence on sleep. Data were collected after eight weeks of continuous use of either a static brace (SB) or a dynamic brace (DB).
Findings / Results: A total of 34 (63%) patients used a SB; 20 (37%) patients used a DB. Problems to the skin such as excoriations, rashes and wounds were reported by 71% in the SB group and by 65% in the DB group. Odor problems from the lining of the brace were reported by 53% in the SB group and by 60% in the DB group. Influence on choice of clothes was reported by 97% in the SB group and by 95% in the DB group. Negative influence on sleep was reported by 76% in the SB group and by 80% in the DB group.
Conclusions: PTS bracing of patients with acute injury to the PCL undergoing non-operative treatment is highly associated with challenges related to problems with the skin, odor, sleep and choice of clothes. Type of brace, static or dynamic, had little influence on challenges associated with brace treatment.

Thomas Støchkel, Lars Tambour Hansen, Michael Brix, Jens Lauritsen
Department of Orthopaedics, Sydvestjysk Sygehus; Department of Orthopaedics, Sydvestjysk Sygehus; Department of Orthopaedics, OUH; Department of Orthopaedics, OUH


Background: Soft tissue swelling in ankle fractures often delays the timing of surgery. We have tried to shorten this delay by using an intermittent pneumatic compression (IPC) device applied around the cast to try and prevent and decrease swelling during admission.
Purpose / Aim of Study: This study aims to investigate IPC’s presumed effects on “time-to-surgery” (TTS) and complication rates.
Materials and Methods: We have conducted a retrospective "before-and- after"-study on patients with acute, closed, surgery dependent ankle fractures admitted to our department from 01.03.11-01.03.15: two years prior (control) and two years after (IPC) implementing the IPC therapy as standard. Additionally, we gathered demographic and general health data on all patients. Our primary outcome measure was TTS from x-ray to surgery. Secondarily complication rates.
Findings / Results: 168 patients were included in the study: 86 in the control group and 80 in the intervention group. Mean TTS – all (control: 25:01 [95% CI 18:50-31:13], IPC: 22:40 [17:27-27:52]); late surgery after 8 hours (control: 32:59 [95% CI 25:03-40:54], IPC: 31:31 [24:48-38,14]). Wound complications (Control: 15% [95% CI 8,3-24,0%] IPC: 9% [95% CI 3,6-17,2%]). No incidents of DVT. No statistical difference in any measures.
Conclusions: This study does not show any effect of IPC in closed ankle fractures but the study does have some weaknesses. The groups are from two different time periods and will therefore contain known and unknown confounders which we have both acknowledge and tried to analyze. Even though this study does not support the use of IPC, it may, in its flaws, have weakened the effect of IPC. Furthermore, separate studies are needed to investigate the effect on open fractures and fractures with external fixation.

Veronique Vestergaard, Alma Pedersen B., Peter Toft Tengberg, Anders Troelsen, Henrik Schrøder
Orthopaedic Surgery, Slagelse Sygehus; Clinical Department of Epidemiology, Aarhus University Hospital; Orthopaedic Surgery, Hvidovre Hospital; Orthopaedic Surgery, Hvidovre Hospital; Orthopaedic Surgery, Næstved Sygehus


Background: Circa 2.000 knee fracture patients are registered in Denmark each year. Knee fractures often result in impaired mobility, pain, early retirement and secondary osteoarthritis. There are currently no large-scale studies on incidence rates (IRs) and descriptions of knee fracture characteristics.
Purpose / Aim of Study: To calculate IRs and describe patient-, fracture- and operative characteristics of knee fractures during 1996-2017.
Materials and Methods: A nationwide cohort study of prospectively collected data from Danish National Patient Registry included all patients with ICD-10 code S724, S820 and/or S821 for knee fracture, and a knee operation code. IRs for registered knee fracture operation codes were computed per 1000 person-years with 95% confidence intervals (CI). The study population was described by fracture type and operation type: external fixation, open reduction internal fixation (ORIF) and knee prosthesis, and the largest subgroup also by sex and age.
Findings / Results: 31.294 knee fracture operation codes were registered, 22.355 were ORIFs, 4.650 were knee prostheses and 2.290 were external fixations. Proximal tibia fracture was the most frequently registered knee fracture type. Proximal tibia plating was the most frequent knee operation coded (n=5.316), mean patient age was 55.7 years and 60.4% were female. 2.815 distal femur fractures were plated. 5.121 patella fractures were wired. IR for registered knee fracture operation codes was 0.24 (95%CI 0.22-0.25) in 1996 increasing to 0.28 (95%CI 0.27-0.29) in 2017, corresponding to an increase of 18 %.
Conclusions: The IR for registered knee fracture operation codes increased by 18 % in 22 years. ORIF is the most common knee operation. Proximal tibia fracture is the most common operated knee fracture type, is most frequently plated and middle-aged females are most likely at risk.

Mads Bech Reinholdt, Sara Birch, Maiken Stilling, Torben Bæk Hansen
Department of Orthopaedic Surgery, Holstebro Hospital; Department of Neurologi og Fysio-ergoterapi, Holstebro Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Holstebro Hospital


Background: Radiographic knee osteoarthritis (RKOA) has been shown to be significantly more prevalent among patients with moderate to severe knee pain and/or severe disability than among patients with no to mild pain and/or lesser disability. However, it is unclear if the severity of RKOA and the severity of clinical symptoms correlate.
Purpose / Aim of Study: To investigate if the severity of RKOA is correlated to the severity of symptoms reported by patients.
Materials and Methods: The study is a first-visit cross-sectional evaluation of a consecutive cohort of 430 patients referred to the knee clinic. Inclusion criteria were knee-OA symptoms (e.g. pain, swelling) and a weight-bearing PA radiograph of the tibiofemoral joint taken within a year of the clinical examination. Prior to clinical examination, all eligible patients were asked to complete the Oxford Knee Score (OKS). The severity of RKOA was graded using the Kellgren-Lawrence Score (KLS). All x-rays were graded by the same observer. 82 patients were excluded: 40 did not meet the inclusion criteria and 42 did not fill out the questionnaire. We used linear regression to evaluate correlation between KLS grade 1-4 and OKS. We used logistic regression analysis to evaluate correlation between the presence of pain and the grade of RKOA. Pain was used as a dichotomous variable and defined as present when reported mild to severe(q1 OKS).
Findings / Results: 348 patients were included (mean age 65yrs (range 25-97), 45% men). No significant correlation was found between KLS grade and OKS score. No significant correlation was found between presence of pain and KLS grade.
Conclusions: We found no correlation between the severity of RKOA and the severity of patient reported knee symptoms including pain. The findings support that treatment of knee osteoarthritis should not be based solely on the severity of RKOA.

Taqi Saidian, Jens Lauritsen, Jesper Schønnemann, Bjarke Viberg
1. Department of Orthopaedic Surgery and Traumatology, Hospital of Southern Jutland; 2. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital; 1. Department of Orthopaedic Surgery and Traumatology, Hospital of Southern Jutland; 3. Department of Orthopaedic Surgery and Traumatology, and Department of Regional Health Research, Kolding Hospital – part of Hospital Lillebaelt, and University of Southern Denmark


Background: A distal radius fracture (DRF) treated with a locking plate is a common procedure but several studies have shown a relative high complications frequency. Studies from hip fracture surgery have demonstrated an association between surgeon charge and complications but this has not been investigated for DRF.
Purpose / Aim of Study: To estimate association between surgeon’s level of experience and complications in patients with DRF treated with volar locking plate.
Materials and Methods: This is a population based register study from the Danish Fracture Database (DFDB). From 01012012 – 31122016 data was extracted on DRF patients using the AO-classification and treated with volar locking plate. Primary outcome is reoperation (specific and all causes), secondary is intraoperative complications. To prevent any loss of reoperation data, we include data from the Danish National Patient Registry (DNPR). Level of experience is divided into novice, trainee, and senior. Groups are compared by chi-square test.
Findings / Results: We included 7,390 DRF from DFDB, 1,456 operated by novice, 2,743 operated by trainee, and 3,225 by senior surgeons. There were 4 intraoperative complications in the novice group, 10 in the trainee, and 12 for senior surgeons yielding no difference (p<0.677). However, there were more breaches in sterility in the novice group (n=9) compared to trainees (n=10) and senior surgeons (n=3) (p<0.004). There were very few reoperations: trainee group (n=4) and senior surgeons (n=4).
Conclusions: The study showed a significant difference in breach of sterility with level of surgical experience in DRF. The main uncertainty and final conclusion regarding reoperations awaits further extracts of surgical procedures from the DNPR due to insufficient reporting to DFDB by of subsequent surgical specialist intervention.

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: In 2012, registration completeness in the Danish Hip Arthroscopy Registry (DHAR) was 64%.
Purpose / Aim of Study: To update registry completeness, including age group differentiation and regional differences.
Materials and Methods: We compared proportions of yearly registrations in DHAR to registrations in the Danish National Patient Registry (DNPR) from inception in 2012 until 2017. We further stratified for age (<25, 25-39, ≥ 40) and hospitals performing hip arthroscopies (five regions of Denmark) in evaluation of baseline differences between responders and non-responders at one- year follow-up.
Findings / Results: From February 2012 to March 2017, 3,851 arthroscopic hip surgeries were registered in DHAR and 4,627 in DNPR. The yearly completion rate increased from 64% for 2012 to 97% for 2016. As of March 2018, 2,449 patients had completed their one-year follow-up questionnaires and of these 44 patients (<1%) had returned their one-year follow-up questionnaire but were not registered at baseline. A significant proportion of those younger than 25 year had not responded to the one-year follow-up questionnaire (38% non-responders). For all age groups, the region of Mid Jutland had the highest proportion of responders (72%), followed by the Capitol Region (68%) and Southern Denmark (64%). North Jutland reported the lowest proportion of responders (57%). The region of Zealand was not included due to small number of reported surgeries (n=9).
Conclusions: A continuous improvement in registration of arthroscopic surgeries in DHAR is seen over time reaching 97% in 2016. The young adults and patients from the Northern part of Denmark had lower return rates at the one-year follow-up.

Søren Ohrt-Nissen, Vijay H. D. Kamath, Dino Samartzis, Keith DK Luk, Jason PY Cheung
Dep. of Orthopaedic surgery, Spine Unit, Copenhagen university hospital, Rigshospitalet; Dep. of Orthopaedics and Traumatology, The University of Hong Kong; Dep. of Orthopaedics and Traumatology, The University of Hong Kong; Dep. of Orthopaedics and Traumatology, The University of Hong Kong; Dep. of Orthopaedics and Traumatology, The University of Hong Kong


Background: Postoperative shoulder imbalance (PSI) remain a common complication after corrective surgery for main thoracic (MT) adolescent idiopathic scoliosis (AIS). However, the criteria for when to extend the fusion proximally and the optimal level of curve correction is not well established.
Purpose / Aim of Study: To identify preoperative predictors for PSI after corrective surgery of adolescent idiopathic scoliosis (AIS).
Materials and Methods: The study included a consecutive surgical cohort of AIS patients undergoing selective thoracic fusion. Preoperative antero-posterior, lateral and fulcrum bending radiographs were analysed. Postoperatively, a minimum of two years clinical and imaging follow-up was performed of all patients. PSI was defined as a radiographic shoulder height difference of more than 20 mm.
Findings / Results: A total of 80 patients were included and 14 patients (18%) were confirmed with PSI at final follow-up. Flexibility of MT curve was an independent risk factor for PSI (odds ratio (OR)= 3.3 per 10% decrease, 95% confidence interval (CI): 1.6-8.2). 27 patients had a preoperative MT flexibility of <55% (OR=11.5, 95%CI: 2.8-46.2). Postoperative T1 tilt was significantly higher in the PSI group (p<0.001) and a T1 tilt of more than 9° resulted in 7.2 times higher odds of developing PSI (95%CI: 2.0-26.0). Fulcrum bending correction index (FBCI) was significantly higher in the PSI group at final follow-up and 25 patients had a final postoperative MT FBCI above 120% (OR=8.5 (95% CI: 2.3-31.0).
Conclusions: A low preoperative curve flexibility is a significant predictor for PSI. The surgical strategy should consider proximal fusion if low-flexibility MT curves and/or less aggressive MT curve correction. Achieving a level T1 should be a main priority during intraoperative correction and may require fusion of the PT curve.

Randi Gram Rasmussen, Birgitte Blaabjerg, Torsten Grønbech Nielsen, Martin Lind
Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital; Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital; Division of Sports Trauma, Department of Orthopedic Surgery, Aarhus University Hospital; Division of Sports Trauma, Department of Orthopedic Surgery , Aarhus University Hospital


Background: Non-operative treatment is first choice in patients with acute isolated grade 1 and 2 ruptures of the posterior cruciate ligament (PCL), grade 3 ruptures are often surgically treated.
Purpose / Aim of Study: To evaluate short term clinical outcome of non-operative treatment of PCL using a posterior tibial support (PTS) brace in combination with a standardized exercise protocol.
Materials and Methods: A prospective cohort study, 50 patients (37 males) with a mean age of 33 years (range 15-61) Data was collected from June 2015 to June 2018. PCL lesions were diagnosed by MRI and treatment was initiated within eight weeks of injury. Mechanism of injury: Sports 74%, traffic 12%, daily activity 10% and work- related 4%. Twenty-three (46%) patients had an isolated PCL injury, Twenty-seven (54%) had a multi- ligament injury and fourteen (52%) of these had knee dislocations. The rehabilitation program: PTS brace for 12 weeks and a 16-week standardized, home-based exercise protocol. Evaluation of PCL healing at 12 weeks: posterior drawer and tibial off- set test. Patients with significant objective PCL instability were offered surgical treatment.
Findings / Results: Seven patients (14%) were converted to PCL reconstruction; two (9%) of these had an isolated PCL ligament injury and five (36%) patients had knee dislocations. Time from initiation of non-operative treatment to PCL reconstruction was a mean of 13 months (range 9,5-14).
Conclusions: Short term outcome of non-operative treatment of PCL using a combination of the PTS brace and a standardized exercise protocol resulted in conversion to PCL reconstruction in 9% patients with isolated PCL lesion and in 36% patients with knee dislocation. Isolated PCL lesions can heal sufficiently with non-operative treatment, whereas knee dislocation PCL injuries have poor healing ability and often will require surgery.

Bo Madvig Larsen, Bo Zerahn, Bent Kristensen, Søren Ribel-Madsen, Arne Borgwardt
Department of Orthopaedic Surgery, Bispebjerg and Frederiksberg University Hospital; Department of Clinical Physiology and Nuclear Medicine, Herlev University Hospital; Department of Clinical Physiology and Nuclear Medicine, Herlev University Hospital; Department of Orthopaedic Surgery, Bispebjerg and Frederiksberg University Hospital; Department of Orthopaedic Surgery, Bispebjerg and Frederiksberg University Hospital


Background: Highly elevated levels of serum metal ions are at times found in patients with metal-on-metal (MoM) hip replacements. However, it is still debated which variables that are contributing to this.
Purpose / Aim of Study: This study seeks to identify whether there is a significant association between the contact patch to rim distance (CPRD) and the anterior center edge angle (ACEA) respectively and serum cobalt (Co) and chromium (Cr) levels in patients treated with unilateral MoM hip replacements by using anteroposterior- and false profile view radiographs.
Materials and Methods: A retrospective analysis was conducted on 53 patients with either unilateral ReCap or M2a- Magnum MoM hip replacements randomized and operated on between 2006 and 2007. Univariate linear regression and multivariable linear regression (MLR) analyses were carried out using the CPRD, ACEA and other published risk factors for elevated serum levels of Co and Cr previously suggested in the literature as explanatory variables. Serum Co and Cr were measured using inductively coupled plasma mass spectrometry.
Findings / Results: The MLR model showed that the same three variables (gender, CPRD and ACEA) were significantly associated with serum levels of both Co and Cr. The univariate analysis showed a polynomial relationship between the anteversion angle and serum levels of Co and Cr with the vertex of the polynomial function located at 20°.
Conclusions: Gender, CPRD and ACEA are independent predictors of serum levels of Co and Cr. CPRD and ACEA are probably indicators of edge loading. This emphasizes the importance of exact inclination and anteversion of the acetabular component in patients undergoing MoM hip replacements, furthermore alternative bearings should be considered to MoM arthroplasty in women.

Josephine Olsen Kipp, Stig Storgaard Jakobsen, Martin Lamm, Kjeld Søballe
Department of Orthopaedic Surgery , Aarhus University Hospital ; Department of Orthopaedic Surgery , Aarhus University Hospital ; Department of Orthopaedic Surgery , Aarhus University Hospital ; Department of Orthopaedic Surgery , Aarhus University Hospital


Background: Two-stage revision is used as treatment of periprosthetic hip joint infection (PHJI). ‘StageOneTM Select Hip Cement Spacer’ prevents contractures, preserves bonestock with the ability to adjust leg length and offset.
Purpose / Aim of Study: The aim of this study is to evaluate complications, bone destruction, mobilization and restoration of natural joint anatomy with the StageOne Select Spacer.
Materials and Methods: From 2013-2017 twenty-one patients had PHJI and received a StageOne Select Spacer. Through review of medical records we obtained the pre- per- and postoperative data and serial x-ray was evaluated.
Findings / Results: One (4.8%) dislocated the spacer hip, one (4.8%) sustained a periprosthetic fracture, two (9.5%) got reinfected and one (4.8%) never succeeded to get control of the infection. Two (9.5%) died unrelated to the spacer implantation. Pre- vs. postoperative leg length was 1.5 mm (-4,8-6.3) and offset was 0.5 mm (-2.3-5.5).
Conclusions: The StageOne Select Spacer shows promising results in treatment of PHJI. Complication rate was equal or lower than other studies and the spacer will restore the natural anatomy of joint, especially on the femoral side.

Christian Bredgaard Jensen, Henrik Husted, Anders Troelsen, Kirill Gromov
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre


Background: Previous studies have reported differences in surgical outcome between first and second operated knee in simultaneous bilateral total knee arthroplasty (SBTKA). Surgical outcome has been related to the alignment of the implanted components. However, potential alignment differences between the first and second knee in SBTKA, and whether any alignment differences can be linked to the specific implant design has not been investigated.
Purpose / Aim of Study: To investigate systematic differences in anatomical component alignment between the first and second knee following SBTKA, and to investigate differences related to implant type.
Materials and Methods: We identified 38 consecutive patients operated with SBTKA between 2015 and 2017. 19 patients were operated with Persona total knee arthroplasty (TKA) system and 19 were operated with AGC TKA system. Component alignment in the AP and lateral plane was measured on postoperative X-rays. Differences between first and second knee were investigated for both implants.
Findings / Results: The second knee had an increased overall varus alignment of 0.8 degrees (p=0.044) compared to the first knee. The tibial component of the second knee had an increased varus alignment of 1.2 degrees (p=0.003) compared to the first knee. Systematic differences for overall and tibial varus alignment were present in AGC TKA, but not in Persona TKA, when analysed separately. The number of outliers with respect to the tibiofemoral axis was higher in the second knee in AGC TKA patients only.
Conclusions: When operating the left knee first in SBTKA, the right knee and the tibial component was placed in slight varus alignment compared to the left knee. This difference was only present in knees operated with the AGC TKA system. This may be worth noting for surgeons performing SBTKA to increase uniformity between the operated knees.

Lene Lindberg Miller, Torsten Grønbech Nielsen, Bjarne Mygind-Klavsen, Martin Lind
Div. of Sports Trauma, Orthopedic Dept. , Aarhus University Hospital, Denmark; Div. of Sports Trauma, Orthopedic Dept. , Aarhus University Hospital, Denmark; Div. of Sports Trauma, Orthopedic Dept. , Aarhus University Hospital, Denmark; Div. of Sports Trauma, Orthopedic Dept. , Aarhus University Hospital, Denmark


Background: This present study evaluated the long-term effect of high volume image-guided injection (HVIGI) for chronic Patella Tendinopathy (PT).
Purpose / Aim of Study: Does HVIGI-treatment for chronic non-insertional PT improve function and reduce pain at a long-term follow-up?
Materials and Methods: Patients with resistant PT who failed to improve with a 3-month heavy slow resistance program were included in the study. Maximal tendon thickness and neovascularisation was assessed with ultrasound and power Doppler. All the tendinopathic patella tendons were injected, ultrasound guided, with 10 mL of 0.5% Marcaine, 0.5 mL Triamcinolonacetonid (40mg/mL) and 40 mL of 0.9% NaCl saline solution under real time ultrasound guidance. All outcome measures were recorded at baseline and after one year. A standardized heavy slow resistance protocol was prescribed after HVIGI-treatment. Clinical outcome was assessed with the Victorian Institute of Sports Assessment-Patella tendon (VISA-P) questionnaire.
Findings / Results: Thirty-six HVIGI procedures were performed in the period 2013-2016. The study included a series of 24 procedures in 22 patients (20 men, 2 women). Mean age 31,9 (range 18-52). Mean duration of symptoms before HVIGI was 44 months. The baseline VISA-P score of 39±16 (range 15-67) improved to 65±22 (range 20-94) by 1 year (p=0,001). 73% of the patients had more than a 10 point improvement at the VISA-P score after one year. Elleven patients (31%) did not respond to treatment with continued pain and referred to surgery (5 patients) or additional HVIGI treatment (6 patients/7 procedures) before 1- year follow-up.
Conclusions: HVIGI-treatment for chronic PT significantly improved function and reduced pain (VISA-P) at long-term follow-up. 31% of the patients did not respond to a single HVIGI treatment.

Catarina Malmberg, Jonas Frederiksen, Anders Troelsen, Ilija Ban, Peter Toft Tengberg, Mads Terndrup
Department of Orthopedics, Copenhagen University Hospital Hvidovre; Department of Orthopedics, Copenhagen University Hospital Hvidovre; Department of Orthopedics, Copenhagen University Hospital Hvidovre; Department of Orthopedics, Copenhagen University Hospital Hvidovre; Department of Orthopedics, Copenhagen University Hospital Hvidovre; Department of Orthopedics, Copenhagen University Hospital Hvidovre


Background: Operative management of the posterior malleolus (PM) in ankle fracture osteosynthesis is an object of increasing attention.
Purpose / Aim of Study: To examine potential risk factors and complication rates after osteosynthesis of ankle fractures involving the PM.
Materials and Methods: Adult patients with ankle fractures treated surgically from June 2011 to December 2015 at our institution were assessed for eligibility. Exclusion criteria were: non-danish citizen, non-operative treatment, treatment >4 weeks after injury or staged procedures, follow-up at an alternative institution, and patients lost to follow-up. Demographics and injury-related risk factors, as well as procedural data, were recorded and fractures were classified from standard radiographs and, if present, CT-scans. Postoperative data included immobilization regimen, access to physiotherapy, complications, unplanned reoperation, and implant removal. Minimum follow-up was 18 months in all cases.
Findings / Results: 764 patients were eligible for review and 367 patients had PM involvement. In 61 patients the PM was fixed, most commonly with anterior to posterior percutaneous screws. 84% of patients were not allowed full weightbearing from day one. The overall complication rate after ORIF of ankle fractures with PM involvement was 20.7%, with a reoperation rate of 10.6%, not including implant removal. 20 of the 61 patients who received operative PM fracture fixation suffered complications (32.8%) and 18% required reoperation.
Conclusions: Patients with ankle fractures involving the PM seem to have a high risk of complication and 10% require reoperation. Although the severity of the injury is a clear selection bias in the group receiving operative fixation of PM fractures, complications in one third of cases seems unacceptably high, calling for further investigation in prospective studies.

Naima Elsayed, Karen Dyreborg, Nikolaj Winther, Jens Stûrup, Michael Mørk Petersen
orthopedic , Rigshospitalet; orthopedic , Rigshospitalet; orthopedic , Rigshospitalet; orthopedic , Rigshospitalet; orthopedic , Rigshospitalet


Background: The Biomet® Modular Revision Femoral System (Arcos Hip) is a comprehensive, press-fit revision stem design that provides the surgeon with multiple styles of modular proximal and distal bodies for reconstruction of various defects commonly seen in femoral revision surgery. It was introduced to the Danish hospitals in 2011 and there has been a limited amount of data presented on this implant.
Purpose / Aim of Study: The purpose of this study is to assess the performance and evaluate the early results after femoral revision with the use of Arcos Hip.
Materials and Methods: In September 2011 to December 2016, 82 patients at Rigshospitalet received an Arcos hip, and 78 patients (mean age=69 (24-91) years, F/M=40/38) were included in the study with a follow up of 1.5 to 7 years. 4 patients were excluded due to the use of the system for a more complicated surgical problem. The primary endpoint was a re-revision using data from the Danish Hip Arthroplasty Registry, the Patient Administrative System and the National Patient Registry. The secondary endpoints are complications (dislocation, fracture, aseptic loosening, infection), the present function of the hip including Harris Hip Score, Oxford Hip Score, EQ5D, and radiographic evaluation
Findings / Results: 11 patients died in the interim and were consequently only included in the survivorship analysis. The early results showed that 12 hips (15,4 %) had complications resulting in fracture (n=3), dislocation (n=8) or soft tissue revision (n=1). Furthermore, in 4 of the patients (5,1%) the Arcos Hip was replaced with a different hip prosthesis. The probability of implant survival at 1 and 5 year was unchanged 94,7% (95%-CI: 89,7% - 99,8%)
Conclusions: The early results showed an acceptable survival of the implant and a promising outcome with the use of the Arcos Hip in a highly specialized hip revision unit.

Rathleff Michael, Winiarski Lukasz, Krommes Kasper, Graven-Nielsen Thomas, Hölmich Per, Olesen Jens, Holden Sinead, Thorborg Kristian
SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University; Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital; Sports Orthopedic Research Center-Copenhagen (SORC-C), Department of Orthopaedic Surgery, Copenhagen University Hospital, Amager-Hvidovre; Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University; Sports Orthopedic Research Center-Copenhagen (SORC-C), Department of Orthopaedic Surgery, Copenhagen University Hospital, Amager-Hvidovre; Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University; SMI, Department of Health Science and Technology, , Faculty of Medicine, Aalborg University; Sports Orthopedic Research Center-Copenhagen (SORC-C), Department of Orthopaedic Surgery, Copenhagen University Hospital, Amager-Hvidovre


Background: Osgood Schlatter Disease (OSD) is common, affecting one in ten adolescents, and particularly the sports active. Severe knee pain, lower-limb strength deficits, and reduced knee function are cardinal findings in OSD. Despite severe knee pain, adolescents with OSD continue with frequent and intense sports participation. This highlights the need for interventions which address functional deficits, while helping adolescents manage their sports load.
Purpose / Aim of Study: The aim of this study was to investigate the effect of load management with progressive knee strengthening in adolescents with OSD.
Materials and Methods: This pre-registered (NCT02799394) prospective cohort study included 51 adolescents (51% female; aged 10-14 years) with OSD. They underwent a 12- week intervention, initially (week 0-4) utilising an activity ladder paradigm designed to manage patellar tendon loading and pain. Subsequently, participants initiated progressive strength exercises (week 4-12), with a gradual return to sport (week 4-12). Primary outcome was self-reported improvement at 12 weeks, evaluated on a 7-point Likert-scale. Successful outcome was pre-specified as reporting ¡§much improved¡¨ or ¡§improved¡¨.
Findings / Results: Adolescents reported an average 21 months („b12.5) pain duration. At 12 weeks, 88% completed the questionnaire with 80% reporting a successful outcome, which increased to 87% at 6 months. At 12 weeks, 40% participated in regular physical activity with 16% back playing sport, these numbers increased to 78% and 64% at 6 months. 71% were satisfied with result of treatment and 96% would recommend it to a friend.
Conclusions: Load management combined with progressive knee strengthening has potential as a treatment for adolescents with OSD and should be explored further.

Adam Omari, Anders Troelsen, Henrik Husted, Thue Ørsnes, Niels Kristian Stahl Otte, Kirill Gromov
Department of Orthopedic Surgery, Hvidovre Hospital; Department of Orthopedic Surgery, Hvidovre Hospital; Department of Orthopedic Surgery, Hvidovre Hospital; Department of Orthopedic Surgery, Hvidovre Hospital; Department of Orthopedic Surgery, Hvidovre Hospital; Department of Orthopedic Surgery, Hvidovre Hospital


Background: New implants for total joint arthroplasty are continuously introduced with the proposed benefit of increased performance and improved outcome. Little information exists on how introduction of a novel arthroplasty implant affects the surgical procedure immediately after implementation.
Purpose / Aim of Study: The aim of this study was to investigate how perioperative factors and early postoperative outcome was affected by introduction of a novel TKA system.
Materials and Methods: A novel TKA system was introduced at our institution in 2015. A total of 75 TKAs performed with the new system immediately following the introduction (25 TKA/ surgeon) were identified as the new group. The latest 25 TKAs performed by each surgeon prior to introduction of the new system were identified as the control group. Demographic-, intraoperative-, and alignment data was collected.
Findings / Results: After introduction of the novel implant, the TKA system was utilized 69%, 53%, and 45% by the three surgeons, respectively. The control group was 4.5 years (P=0.009) younger compared to the new group showed no difference in gender, BMI, pre- operative TFA, and ASA score. Mean time of surgery and mean intra-op blood loss was increased by 28% (P=0.002) and 38% (P=0.002), respectively. In regard to alignment, femoral flexion (FF) was increased in the new group by 2.0 degrees (P<0.0001). Tibial slope (TS) was on the contrary decreased by 4.7 degrees (P<0.0001). Differences in AP-alignment of tibia, femur, and post-op TFA were non-significant.
Conclusions: Introduction of a new TKA implant increased surgical time and blood loss, with only minor changes in respect to alignment. Further studies are needed to investigate if these differences persist over time and correlated to patient reported outcomes. Surgeons should express increased care when introducing new procedures.

Casper Falster, Simon Poulsen, Arne Storås, Henrik Schroeder, Jesper Vinther, Moustapha Kassem, Uffe Jørgensen
Stem cell research unit (KMEB), Department of Endocrinology, Odense University Hospital; Department of Orthopedic Surgery and Sports traumatology, Odense University Hospital; Department of Orthopedic Surgery and Sports traumatology, Odense University Hospital; Department of Orthopedic Surgery, Næstved Hospital; Department of Orthopedic Surgery and Sports traumatology, Odense University Hospital; Stem cell research unit (KMEB), Department of Endocrinology, Odense University Hospital; Department of Orthopedic Surgery and Sports traumatology, Odense University Hospital


Background: Bone fractures are a common cause of hospital admission for patients of all age groups. In recent years, regenerative medicine has introduced a possible new addition to already established treatments. Evidence suggests that autologous mesenchymal stem cells (MSC) can enhance bone regeneration, by differentiating into bone-forming osteoblasts.
Purpose / Aim of Study: This study aims to investigate if MSCs isolated from bone marrow in sites of recent trauma or osteoarthritis (OA), exhibit reduced proliferative capacity and osteogenic differentiation capability in- vitro, compared to MSCs isolated from non- traumatic and non-OA sites. If these are of reduced quality, clinicians should prioritize bone marrow from unafflicted sites.
Materials and Methods: 17 patients were enrolled. 7 had recent unilateral trauma to the knee, requiring arthroscopy. 10 had x- ray verified unilateral OA and were scheduled for total knee arthroplasty. MSCs were isolated from bone marrow aspirated from both distal femurs of all participants. In-vitro osteogenic activity was assessed through alkaline phosphatase measurement, RNA-expression and alizarin red staining. Proliferation was measured using a growth curve.
Findings / Results: 29 out of 34 primary cultures were succesful. There was no difference in mononuclear cell yield of aspirates or yield of MSCs from primary culture between non-OA and OA knees or non-traumatic and traumatic knees. There was no significant difference in in-vitro osteogenic capability or proliferative capacity.
Conclusions: We found no difference in proliferation or osteogenic differentiation of MSCs isolated from both distal femurs of patients with unilateral trauma or OA of the knee, suggesting that MSCs isolated from sites afflicted by OA or trauma, can be utilized for bone regeneration with identical results as MSCs isolated from uninjured sites.

Casper Dragsted, Dahl Benny, Søren Ohrt-Nissen, Thomas Andersen, Martin Gehrchen
Spine Unit, Orthopaedic Surgery, Rigshospitalet and University of Copenhagen; Department of Orthopedics and Scoliosis Surgery, Texas Children’s Hospital and Baylor College of Medicine, TX, USA; Spine Unit, Orthopaedic Surgery, Rigshospitalet and University of Copenhagen; Spine Unit, Orthopaedic Surgery, Rigshospitalet and University of Copenhagen; Spine Unit, Orthopaedic Surgery, Rigshospitalet and University of Copenhagen


Background: Various distraction protocols have been reported for Magnetically Controlled Growing Rods (MCGR) in the treatment of early-onset scoliosis. Recent studies show a discrepancy between intended distraction and true distraction length which underlines the need for a simple and reliable distraction protocol.
Purpose / Aim of Study: Examine the efficacy of standardized protocol with intended distraction-to-stall by assessing spinal growth and distraction length in patients treated with MCGR.
Materials and Methods: Retrospective study of a single-center cohort. Patients treated with dual MCGR and minimum 3 distractions were included. Conversion cases were excluded. Distractions were performed with intervals of 2-3 months and the intention of distracting-to-stall on both rods. Distraction length and curve correction were monitored on x-rays every 6 months. Spinal growth was assessed using T1-T12 and T1-S1 height.
Findings / Results: 19 patients (8 idiopathic and 11 non-idiopathic) were included. Mean age at surgery was 9.7±1.9 years and median follow-up was 2.2 years [IQR 1.8-2.6]. Major curve improved from median 76° preoperatively [IQR 64-83] to 42° postoperatively [IQR 32-51] (p<0.001) corresponding to a curve correction of 43% [IQR 33-51]. Correction was maintained at 1 and 2-year follow-up. Median annual T1-T12 and T1-S1 length increased 7 mm [IQR 5-12] and 9 mm [IQR 5-17] respectively. 194 distraction procedures were performed; 78% of these were distracted-to-stall and 22% were stopped at discomfort. Median annual rod distraction was 9.3 mm [IQR 6.2-12.5] for the concave side and 8.3 mm [IQR 6.2-10.7] for the convex side. Five patients had implant- related complications leading to unplanned re- operations in 4 patients.
Conclusions: A distraction-to-stall procedure ensures spinal growth with complication rates comparable to the available literature.

Stina Andersen, Regner Birkelund, Mikkel Andersen, Leah Carreon, Karina Dahl Steffensen
Spine Surgery and Research, Spine Center of Southern Denmark, Lillebaelt Hospital, Middelfart, Denmark; Health Services Research Unit, Lillebaelt Hospital, Vejle, Denmark; Spine Surgery and Research , Lillebaelt Hospital, Middelfart, Denmark; Spine Surgery and Research , Lillebaelt Hospital, Middelfart, Denmark; Center for Shared Decision Making , Lillebaelt Hospital, Vejle, Denmark


Background: The decision about if and when to have surgery for lumbar disc herniation (LDH) when no major neurological deficits are present can be complex. Considering the inconclusive evidence regarding the timing of surgery and ambiguous evidence on long term outcomes it is essential to involve patients in decision-making before potential surgery.
Purpose / Aim of Study: To explore from a patient perspective what affect the decision-making process on whether or not to have surgery for symptomatic LDH.
Materials and Methods: Fourteen candidates for primary surgery due to LDH were interviewed. A hermeneutic-phenomenological approach was used to uncover the process of decision-making as it was experienced by the patients through their life-world stories. All interviews were transcribed and analyzed using a meaning- condensation method. Natural meaning units were identified and categorized in to four main themes. Data were analyzed in a theoretical perspective of Shared Decision-making.
Findings / Results: Four main themes appeared to influence the patients’ decision-making process: Patient information: Patients’ conceptions about treatment and risk were not always based on sufficient information and could affect their initial preference for treatment. Accelerated workflows: some patients needed time to process the information given, which may be limited due to accelerated hospital workflows. Power imbalance: patients can be reluctant to challenge the system, as they do not want to offend, which can be seen as a power imbalance between clinicians and patients. Personal past experience: experience from relatives can have a great impact on the patients’ thoughts about possible treatments.
Conclusions: Understanding these complex factors that influence the decision-making process will hopefully help surgeons to better support patients choosing treatment for LDH.

Tanvir Johanning Bari, Søren Ohrt-Nissen, Martin Gehrchen, Benny Dahl
Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital; Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital; Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital; Department of Orthopedics and Scoliosis Surgery, Texas Children’s Hospital and Baylor College of Medicine, TX, USA


Background: Surgical treatment for Adult Spinal Deformity (ASD) is associated with a high risk of mechanical failure and consequent revision surgery. To improve prediction of mechanical complications, the Global Alignment and Proportion (GAP) score was developed with promising results. Development was based on the assumption that not all patients would benefit from the same fixed radiographic targets as pelvic incidence is an individual, morphological parameter that greatly influences the sagittal curves of the spine.
Purpose / Aim of Study: To validate the GAP score in a single-center cohort of ASD patients.
Materials and Methods: All patients undergoing ASD surgery with ≥4 levels of instrumentation were consecutively included at a tertiary spine unit. Patients were followed for a minimum of two years. Pre- and postoperative GAP score and categories were calculated for all patients and the association with mechanical failure and revision surgery was analyzed.
Findings / Results: A total of 149 patients with a mean age of 57.4 years were included. Rates of mechanical failure and revision surgery were 51% and 35% respectively. The area under the curve (AUC) using receiver operating characteristic was classified as “no or low discriminatory power” for the GAP score in predicting either outcome (AUC=0.50 and 0.49 respectively). Similarly, there were no significant associations between GAP categories and mechanical failure or revision surgery when using Cochran-Armitage test of trend (p=0.28 and p=0.58 respectively).
Conclusions: In a consecutive series of surgically treated ASD patients we found no significant association between postoperative GAP score and mechanical failure or revision surgery. Despite minor limitations in similarities to the original study cohort, further validation studies or adjustments to the original scoring system are proposed.

Torsten Grønbech Nielsen, Lene Lindberg Miller, Bjarne Mygind-Klavsen, Martin Lind
Div. Sports Trauma, Orthopedic Dept, Aarhus University Hospital; Div. Sports Trauma, Orthopedic Dept, Aarhus University Hospital; Div. Sports Trauma, Orthopedic Dept, Aarhus University Hospital; Div. Sports Trauma, Orthopedic Dept, Aarhus University Hospital


Background: This present study evaluates the long- term effect of high volume image- guided injection (HVIGI) for chronic non-insertional Achilles Tendinopathy (AT).
Purpose / Aim of Study: Does HVIGI-treatment for chronic non- insertional AT improve function and reduce pain at a long-term follow-up?
Materials and Methods: Patients with resistant non-insertional AT who failed to improve with a 3-month eccentric loading program were included in the study. Maximal tendon thickness and neovascularisation was assessed with ultrasound and power Doppler. All the tendinopathic Achilles tendons were injected, ultrasound guided, with 10 mL of 0.5% Marcaine, 0.5 mL Triamcinolonacetonid (40mg/mL) and 40 mL of 0.9% NaCl saline solution under real time ultrasound guidance. All outcome measures were recorded at baseline and after one-year follow- up. A standardized eccentric loading rehabilitation protocol was prescribed after HVIGI-treatment. Clinical outcome was assessed with the Victorian Institute of Sports Assessment-Achilles tendon (VISA-A) questionnaire.
Findings / Results: Fifty-four HVIGI procedures were performed in the period 2013-2016. The study included a series of 41 procedures in 33 patients (26 men, 7 women). Mean age 44,4 (range 16- 63). Mean duration of symptoms before HVIGI was 36 months. The baseline VISA-A score of 48±15 (range 14-74) improved to 62±21 (range 31- 94) by 1 year (p=0,018). 50% of the patients had more than a 10 point improvement at the VISA-A score after one year. Eleven patients (34%) did not respond to treatment with continued pain and had surgery (2 patients) or additional HVIGI treatment (9 patients/11 procedures) before 1-year follow-up.
Conclusions: HVIGI-treatment for chronic non- insertional AT significantly improved function and reduced pain (VISA-A) at long-term follow-up. 34% of the patients did not respond to a single HVIGI treatment.

Martin Lind, Torsten Grønbeck Nielsen, Kevin Jacobsen
Orthopedics, Aarhus University Hospital; Orthopedics, Aarhus University Hospital; Orthopedics, Aarhus University Hospital


Background: MCL lesions normally heal non-operatively but grade 3 lesions can result in chronic valgus instability, which needs surgical treatment with MCL reconstruction. Outcome data after MCL reconstruction are limited represented by small sized case studies.
Purpose / Aim of Study: The aim of this study is to present objective knee stability and subjective outcome in patients after isolated MCL reconstruction and combined MCL+ACL reconstruction and compare these with outcomes from isolated ACL reconstruction based on results from DKRR. We hypothesized improved valgus stability and subjective outcome after MCL reconstruction.
Materials and Methods: Respectively 103, 495 and 24.683 of isolated MCL, combined MCL+ACL and isolated ACL reconstructions were registered in the (DKRR) between 2005 and 2016. Objective outcomes of valgus and sagittal knee laxity and patient-reported outcome (KOOS) at one-year follow-up was used to compare the outcome of the 3 cohorts.
Findings / Results: Medial stability improved significantly from pre- to postoperatively for both isolated a MCL and combined MCL+ACL reconstruction with 53 and 69 % having normal valgus stability (0-2 mm laxity) respectively. MCL+ACL reconstruction obtained similar sagittal stability as isolated ACL reconstructions of 1,7 and 1,5 mm respectively. KOOS outcome demonstrated that both isolated MCL and combined MCL+ACL reconstruction improved significantly to similar score levels from pre- op to one-year but scores were lower than isolated ACL reconstructions.
Conclusions: Both isolated MCL and combined MCL+ACL reconstruction obtained improved subjective outcomes and valgus stability with a high percentage of normalized stability. But with poorer subjective outcome than isolated ACL reconstructions. Combined MCL+ACL reconstructions had similar sagittal stability as isolated ACL reconstructions.

Sten Rasmussen, Georgia Chan, Perla J. Marang-Van De Mheen, Ove Talsnes, Andrew Gordon
Department of Orthopaedic Surgery, Aalborg University Hospital; Dr Foster/Telstra Health, Imperial College London, UK; Department of Medical Decision Making,, Leiden University Medical Center, The Netherlands; Department of Orthopaedic Surgery, Elverum Hospital, Norway; Department of Orthopaedic Surgery, Sheffield University Hospital, UK


Background: An increasing number of patients with ch chronic diseases such as degenerative sp spine, hip and knee need operative treatment. During the last d decades, the population health has i increased. The number of hospital beds and the length of hospital stay (LOS) has decreased.
Purpose / Aim of Study: The question is whether we can expect this decrease in length of stay to co to continue, in a linearly fashion or wheth whether this decrease will level off? The purpose of this analysis was to ev evaluate the trends in LOS for lumbar fu fusion, total hip (THA) and knee arthroplasty (TKA) and hip f fractures in hospitals participating in t the Global Comparators international benchmarking collaborative.
Materials and Methods: We explored hospital administrative d data for the period 2008 through 2014 f for 34 University Hospitals from Australia, Belgium, Denmark, Finland, Great Britain, Italy, Netherlands and USA. We used fixed a and random effects modelling, adding country as a grouping variable. We included data on 15905 lumbar fusion 56772 THA, 69182 THA and 47104.
Findings / Results: For lumbar fusion, there was no change in LOS. For THA, there was reduction in LOS from 8.1 to 4.6 days. Adjusted the reduction in LOS decreased by year (P < 0.001). For TKA, there was a reduction in LOS from 7.7 to 4.5 days. Adjusted the reduction in LOS decreased by year (P < 0.001). For hip fracture, there was a minor reduction in LOS from 4.9 to 4.5 days. Adjusted the reduction in LOS decreased by year (P < 0.001).
Conclusions: Mean LOS reduced after THA, TKA and and hip fractures but this trend seems to to level off. For hip fracture, there is an indication that LOS have re reached a plateau. For lumbar fusion, we we found no change in LOS. Given increasing numbers of elderly, t this suggests that hospital capacity m might have to increase as reduction in LOS cannot compensate the increasing number of patients.

Anders Tjønneland, Janus Duus, Mogens Laursen, Poul Torben Nielsen
Ortopædkirurgisk, Aalborg; Ortopædkirurgisk, Aalborg; Ortopædkirurgisk, Aalborg; Ortopædkirurgisk, Aalborg


Background:
Purpose / Aim of Study: To evaluate if there is any difference in hip parameters femoral offset, femoral leg length and neck shaft angle (NSA) after total hip arthroplasty (THA) using Primoris uncemented femoral neck prosthesis, with and without use of an intraoperative guide system
Materials and Methods: Femoral offset, femoral leg length and NSA on the operated hip, were compared to the contralateral anatomical hip on the pelvic x-ray taken 1 year after surgery. Measurement were made in Traumacad. 52 patients was operated using the guide (ReCap Ks Jig) and 50 patients not using the guide, 9 and 14 x-rays respectively were excluded. One surgeon operated all the patients. Functional outcome was assessed using the Harris Hip Score (HHS)
Findings / Results: Compared to the contralateral hips, the operated hips femoral offset had a mean shortening of 2,3mm (p=0,018) with the guide, and a mean shortening of 0,7 mm (p=0,47) not using the guide. Femur length had a mean shortening of 5 mm (p=2,5*10-9) using the guide, and a mean shortening of 5,9 mm (p=3,6*10-10) not using the guide. The implant was placed in 15O (p=9,2*10-14) valgus with the guide, and 13O (p=3,7*10-13) valgus without the guide. Comparing using the guide vs not using the guide operatively we found no difference in femoral offset (p=0,26), femoral length (p=0,32) and NSA (p=0,50). The HHS improved at one year after surgery, from a mean of 56 to 93 with the guide, and from 55 to 97 without the guide. There is a tendency towards, that the patients who were operated with no guide, got a higher HHS, but it was not statistical significant (p=0,08).
Conclusions: There is no significant difference in femoral offset, femoral leg length and NSA, on the pelvic x-ray taken 1 year postoperatively, whether using or not using the operative guide system for positioning the Primoris hip prosthesis.

Lasse Ishøi, Kristian Thorborg, Otto Kraemer, Per Hölmich
Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery , Copenhagen University Hospital, Amager-Hvidovre, Denmark; Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery , Copenhagen University Hospital, Amager-Hvidovre, Denmark; Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery , Copenhagen University Hospital, Amager-Hvidovre, Denmark; CSports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery , Copenhagen University Hospital, Amager-Hvidovre, Denmark


Background: Following hip arthroscopy for femoroacetabular impingement syndrome (FAIS) <20% of athletes return to optimal sport performance. However, it is unknown if specific athletic movements are important for reaching optimal sport performance.
Purpose / Aim of Study: This study aimed to compare self-reported problems in athletic movements between athletes reporting optimal sport performance and impaired performance following hip arthroscopy for FAIS.
Materials and Methods: Subjects were identified in the Danish Hip Arthroscopy Registry, and invited to answer 1) a return to sport questionnaire investigating self- reported sport performance and 2) the Copenhagen Hip and Groin Outcome Score (HAGOS) sport subscale investigating problems in athletic movements. Subjects were dichotomized based on self-reported sport performance (optimal performance vs. impaired performance). The proportion of athletes reporting no problems (none; mild) and problems (moderate; severe; extreme) on HAGOS sport subscale questions were compared between groups.
Findings / Results: 184 athletes were included. 31 athletes (16.8%) reported optimal sport performance, whereas 153 athletes (83.2%) reported impaired sport performance. The minority (<20%) of those who reported optimal sport performance had problems in athletic movements. Contrary, subjects who reported impaired performance often had problems with high- load athletic movements such as running fast (64%), kicking/skating (58%), explosive movements (60%), and outer hip positions (70%).
Conclusions: Most athletes with impaired performance following hip arthroscopy for femoroacetabular impingement syndrome have problems in high-load activities such as running fast, kicking/skating, explosive movements, and outer hip positions. Such information may guide future focus on post-operative rehabilitation for femoroacetabular impingement.

Camilla Holmenlund, Søren Overgaard, Randi Bilberg, Claus Varnum
Department of Orthopaedic Surgery and Traumatology, Odense University Hospital ; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital , Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark; Department of Clinical Research, Unit of Clinical Alcohol Research, University of Southern Denmark; Department of Orthopaedic Surgery, Section for Hip and Knee Replacement, Vejle Hospital


Background: The Oxford Hip Score (OHS) is often used when evaluating the outcome after total hip arthroplasty (THA). The OHS was developed more than twenty years ago with some degree of patient involvement. We speculate if the OHS is still relevant for the patients before and after THA.
Purpose / Aim of Study: The aim of this study was through focus group interviews to determine if the OHS contains the items that today’s patients find relevant pre-op., and at 3 and 12 months post-op.
Materials and Methods: Patients aged 60-75 years with primary osteoarthritis receiving THA were recruited from OUH and Vejle Hospital for focus group interviews pre-op. and at 3 and 12 months post-op. Six focus group interviews were conducted totaling 30 patients of whom two were excluded in the data analysis, as they did not fulfill the inclusion criteria. The interviews were audio-recorded and transcribed verbatim. Interview transcripts were inductively organized into categories using thematic analysis.
Findings / Results: When comparing categories identified from the interviews to the items of OHS, we found that items such as pain and walking were very important to all three groups of patients. Items such as limping was only important pre-op and 3 months post-op. and not mentioned at 12 months. Furthermore, we identified several categories that the OHS does not cover, including cycling, the ability to get on the floor, sport and quality of life, that were found to be very important to the patients pre-op. and post-op.
Conclusions: We showed that the OHS lacks several dimensions according to the patients. Our study suggests that other patient-reported outcome measures (PROMs) than the OHS should be used when evaluating the outcome of THA. It may indicate a need for a new PROM to evaluate the outcome for these patients.

Anders Paulsen, Marianne Lind, Thomas Colding, Michael Mørk Petersen
Orthopeadic Department, Righospitalet; Orthopaedic Department, Rigshospitalet; Orthopaedic Department , Rigshospitalet; Orthopaedic Department, Rigshospitalet


Background: Previous studies comparing operative and non-operative treatment for displaced intraarticular calcaneus fractures (ICF) have reported conflicting findings.
Purpose / Aim of Study: Describe the demography of our patient cohort and quantify the early complication rate and the radiological results after surgical treatment of ICF.
Materials and Methods: In 2013-2016 we operated 167 consecutive patients (49 (7-91) years, F/M= 35/132) with 179 calcaneus fractures, 155 were ICF. All fractures were evaluated pre- and post- operatively with plain X-rays and CT. ICF were classified by the Sanders classification (type 2 (n=99), type 3 (n=40), type 4 (n=8)) or were sustentaculum fractures (n=8) and the extraarticular fractures were beak fractures (n=24). The operative technique was selected by the surgeon and was for the ICF osteosynthesis (using a sinus tarsi (n=90) or L/J shaped lateral approach (n=55)) or primary arthrodesis (n=10). Statistics: Wilcoxon test.
Findings / Results: For 126 ICF treated with plate osteosynthesis and complete pre- and postoperative X-rays the mean (range) Bohler's angle (BA) was improved by 17 degrees (p<0.001) from a preoperative BA of mean 11 (-20-40) to a postoperative BA of mean 28 (11- 41). The mean (range) Gissane’s angle (GA) was improved by 16 degrees (p<0.001) from a preoperative GA of 109 (25-147) to a postoperative GA of 125 (104-147). 137 ICF treated with plate osteosynthesis had a postoperative joint congruence with a perfection reduction (0 mm) in 48 % and acceptable reduction (1-2 mm) in 42 %. 5 ICF were revised within the 2 months postoperatively because of deep infection (n=4, arthrodesis/lateral approach=1/3) or substandart osteosyntesis (n=1, sustentaculum fracture).
Conclusions: We found a statistically significant improvement in BA and GA after osteosynthesis of ICF and a low revision rate for deep infection.

Kirill Gromov, Anders Troelsen, Maziar Modaddes , Ola Rolfson, Ove Furnes, Geir Hallan, Antti Eskelinen, Neuvonen Perttu , Henrik Husted
Department of Orthopaedic Surgery, Hvidovre Hospital; Department of Orthopaedic Surgery, Hvidovre Hospital; Department of Orthopaedics, Sahlgrenska University Hospital; Department of Orthopaedics, Sahlgrenska University Hospital; Department of Orthopaedics, Haukeland University Hospital; Department of Orthopaedics, Haukeland University Hospital; Department of Orthopaedics, COXA Hospital for Joint Replacement; Department of Orthopaedics, COXA Hospital for Joint Replacement; Department of Orthopaedic Surgery, Hvidovre Hospital


Background: Postoperative mobilization restrictions have traditionally been applied following total hip arthroplasty (THA) in an attempt to reduce the risk of dislocation. However, recent studies have questioned the effect and rationale underlying such restrictions.
Purpose / Aim of Study: The purpose of this questionnaire based study was to investigate the use of postoperative restrictions and describe differences in mobilisation protocols following primary THA in Denmark (DK), Finland (FIN), Norway (NO) and Sweden (SWE).
Materials and Methods: All hospitals performing primary THA’s in participating countries were identified from the latest national THA registry rapports. A questionnaire containing questions regarding standard surgical procedure, use of restrictions and postoperative mobilization protocol was distributed to all hospitals through national representatives for each arthroplasty registry.
Findings / Results: 77%, 78%, 74% and 84% of hospitals in DK, FIN, NO and SWE returned the completed questionnaire. This corresponded to 98%, 94% 83% and 87% of all primary THA’s performed in the respective countries. Posterolateral approach and neutral liner was used by 77% and 65% of the hospitals respectively. 93% of the hospitals had a standardized mobilization protocol and 98% allowed immediate full bearing. 50%, 43%, 36% and 19% of the hospitals in DK, FIN, NO and SWE, respectively, did not have any postoperative restrictions. If utilized, restrictions were applied for a median of 6 weeks. 68% of all hospitals changed their mobilisation protocol within the last 5 years – all to a less restrictive protocol
Conclusions: Use of postoperative restrictions following primary THA differs between Scandinavian countries, with 19% to 50% allowing mobilization without any restrictions. There is a strong tendency towards less restrictive mobilisation over the last 5 years

Christian Skovgaard Nielsen
Department of Orthopedics , Copenhagen University Hospital, Hvidovre


Background: For patients undergoing primary Total Knee Arthroplasty (TKA) and contemporary anticoagulation treatment (AK) with vitamin-K antagonist (VAK), studies have shown an unacceptable high frequency of thromboembolic (TE) complications with discontinued VAK, especially in patients requiring bridging therapy.
Purpose / Aim of Study: The aim of this descriptive study was to describe intraoperative, 24 h calculated total blood loss (TBL) and complications in patients undergoing TKA without discontinuing VAK.
Materials and Methods: Nine consecutive patients in VAK treatment were enrolled prior to primary TKA surgery. All were operated without VAK discontinuation in a fast-track setup without use of tourniquet. The results were descriptively compared to published TBL for non-VAK patients in an identical TKA setup.
Findings / Results: Seventy-seven % were men, median age and BMI were 77 y (IQR 69y-80y) and 31 (IQR 26-35), respectively. Regarding TE risk, 7 patients had a CHADS score of 3 or higher (characterized as high risk of TE complications). Preoperatively measured International Normalized Ratio (INR) was 2,7 (IQR 2,5-2,9). Intraoperative blood loss and calculated TBL were 200 ml (100-200 ml) and 1219 ml (IQR 1053-1377 ml), respectively. One patient received blood transfusion. No complications related to anticoagulation or surgery within 90 days were recorded.
Conclusions: Performing TKA without discontinuation of VAK might increase TBL slightly compared to primary TKA patients without VAK treatment, performed in an identical fast track setup (CS. Nielsen, JBJS 2016), with mean intraoperative blood loss and TBL of 200 ml (150-250ml) and 1017 ml (±519ml), respectively. However, considered the frequency of TE complications with discontinued VAK for high-risk patients, this descriptive study indicates a benefit of not discontinuing VAK for TKA surgery.

Simon Toftgaard Skov, Sebastiaan P.J. Wijdicks, Haisheng Li, Kruyt Moyo, René Castelein, Cody Bünger
Dep. of Orthopaedic Surgery, Aarhus University Hospital; Dep. of Orthopaedic Surgery, University Medical Center Utrecht, The Netherlands; Dep. of Orthopaedic Surgery, Aarhus University Hospital; Dep. of Orthopaedic Surgery, University Medical Center Utrecht, The Netherlands; Dep. of Orthopaedic Surgery, University Medical Center Utrecht, The Netherlands; Dep. of Orthopaedic Surgery, Aarhus University Hospital


Background: The MCGR method for growth sparing treatment of severe early onset scoliosis has gained popularity lately worldwide, because of the non-invasive lengthenings. Disadvantages are: high initial costs and lack of apical control. To overcome these, we combined a single concave MCGR with a contralateral sliding rod system with apical control.
Purpose / Aim of Study: To investigate the feasibility, 3D correction, spinal growth and complications of this new MCGR-hybrid principle after minimum 2 years of interval lengthenings.
Materials and Methods: A consecutive series of patients treated with this new principle at two European spine centers were evaluated retrospectively, including all patients operated between Sept. 2014 and June 2016. Demographics and clinical parameters were recorded from patient files. Length, Cobb angles and rotation (Nash-Moe method), were measured on standard digital radiographs.
Findings / Results: 18 patients with a median age at treatment of 9 years with a mean follow- up time of 3 years (range 2-3.7). The frontal Cobb angle was reduced from mean 59 pre-op to 30 post-op and slightly increased to 36 at latest follow- up. Rotation of the apical vertebra improved from mean 27 to 18 post-op but was partially lost to 24 during follow- up. Kyphosis increased 5 degrees during follow-up. Instrumented spine growth was mean 12 mm/year the first year and averaged 10 mm/year at last follow-up. There were 8 total complications, with 7 device related complications. 3 patients required unplanned revision; two because of failure of MCGR distraction and one because of rod breakage. There were no infections.
Conclusions: 3D correction was satisfactory and spinal growth maintained with few complications. This new apical control single growth engine approach seems cost-effective in providing 3D correction and to maintain spinal growth in EOS.

Casper Ferløv Winther, Claus Varnum, Per Kjærsgaard-Andersen, Henrik Husted, Anders Troelsen, Kirill Gromov
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark; Section for Hip and Knee Replacement, Department of Orthopaedic Surgery, Vejle Hospital, Vejle, Denmark; Section for Hip and Knee Replacement, Department of Orthopaedic Surgery, Vejle Hospital, Vejle, Denmark; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark


Background: New implants are continuously introduced in joint arthroplasty in attempt to improve outcome and reduce complications. Monitoring of such implants is required to identify early failures and complications.
Purpose / Aim of Study: To describe early outcome following revision of periprosthetic femoral fractures (PFF) using ARCOS revision total hip arthroplasty (rTHA) with a minimum 1-year follow-up.
Materials and Methods: 41 patients revised using ARCOS THA between 01.01.2014 and 01.03.2017 due to a PFF were identified at two centers. Patient- and surgery- related data was recorded including time from primary surgery until fracture, Dorr type, and measured canal flair index. Surgical parameters included intraoperative complications, fracture reduction, canal fill, and stem length under fracture. Radiological examination at a minimum 12 months follow-up included subsidence and fracture dislocation. All revisions were identified.
Findings / Results: 3 patients died before 1-year follow-up. One patient was lost to follow-up. Mean age was 73.9 years and 73% were female. Mean time from primary THA was 1.8 years. Mean follow-up time for patients who did not have a second revision was 2.8 years. There were no intraoperative complications. A total of 6 patients had a second revision due to infection (2), periprosthetic fracture (2), dislocation (1), and loose cables (1). There were 63% hips with Dorr type A, 21 % with type B, and 15 % with type C. The mean stem length under fracture was 90 mm, mean canal fill in AP projection was 98% and 92% in lateral projection. All fractures were reduced to anatomic or near anatomic reduction. Mean subsidence was 3.3 mm. 22 % subsided > 5 mm.
Conclusions: ARCOS rTHA used for treatment for PFF had an acceptable early complication rate and subsidence comparable to other modular revision systems.

Spogmai Zadran , Andreas Kiesbye Øvlisen, Peter Heide Pedersen, Torben Tvedebrink, Søren Peter Eiskjær
Orthopedic department, Aalborg University Hospital; Orthopedic department, Aalborg University Hospital; Orthopedic department, Aalborg University Hospital; statistisk ved Matematisk Institut, Aalborg University ; Orthopedic department, Aalborg University Hospital


Background: Vertebral osteomyelitis (VO) is a disease targeting the frail. Surgical treatment of VO is major surgery. The question is if major surgery in this population is justifiable.
Purpose / Aim of Study: First, to evaluate the mortality outcome of surgical treatment of VO at our institution compared with patients treated conservatively. Second, to evaluate factors influencing the mortality after VO.
Materials and Methods: Inclusion criteria: all patients diagnosed with VO in the North Denmark Region in the years 2004-2013, identified by searching the Danish National Registry of Patients. All patients were treated at a single institution. Exclusion criteria: treatment not following standardized guidelines, patients younger than 18 years, or previous treatment for VO. Kaplan-Meier analysis was used to evaluate mortality differences between the two treatment modalities. Penalized Cox proportional hazard was used for the predictive modeling of factors influencing mortality
Findings / Results: 125 patients, 89 males and 36 females, were included in the study. Mean age was 67(38-92) years. 75 of which received surgical treatment and 50 conservative treatment. No significant difference in mortality was found after one, two and five years, comparing surgical and conservative management. Significant factors included in the predictive model were the presence of cardiovascular disease, Charlson Comorbidity Index (CCI), infection of the thoracic spine, Karnofsky score and delayed treatment with antibiotics
Conclusions: Patients undergoing surgical management according to standardized guidelines showed no higher mortality than those allocated to conservative treatment. The treatment modality was without importance, but cardiovascular disease, CCI, thoracic infection, Karnofsky score and delayed antibiotic treatment were associated with an increased mortality

Linn Woythal, Per Hølmer, Stig Brorson
Dept. of Orthopedic Surgery, Nordsjællands Hospital, Hillerød; Dept. of Orthopedic Surgery, Nordsjællands Hospital, Hillerød; Dept. of Orthopedic Surgery, Zealand University Hospital, Køge


Background: In the rehabilitation of flexor tendon lesions of the hand splinting with or without the wrist immobilized can be used. The evidence base for these splinting techniques has not previously been studied in a systematic review.
Purpose / Aim of Study: To systematic review the evidence of splinting with or without immobilization of the wrist following surgical repair of flexor tendon lesions.
Materials and Methods: We searched five bibliographic databases. We included randomized controlled trials and observational comparative studies. We excluded studies including patients with additional nerve injury, patients undergoing tenolysis surgery and adolescents. Reference lists were retrieved for additional studies. Study selection and data extraction was performed independently by two authors and controversies were resolved by consensus. Data on patient-reported functional outcome and pain were primary outcomes and health professional-reported functional outcomes were secondary. The review protocol was pre-registered in PROSPERO.
Findings / Results: We identified 1,643 references. No randomized trials but four comparative studies with historical control groups were identified. Two studies were excluded due to additional nerve injury leaving two studies for inclusion: One study including 18 patients reported that a splint that does not immobilize the wrist can be used safely in FDP zone I repairs. Another study including 44 patients reported a 91 % “excellent” total active motion on the Strickland score in the group with active wrist motion. None of the included studies reported our primary outcome measures.
Conclusions: No high-quality evidence comparing postoperative splinting with or without immobilization of the wrist was identified. Randomized trials should be conducted to inform rehabilitation after flexor tendon repair.

Rune Vinther Madsen, Signe Rosenlund, Susanne Mallet
Department of Orthopaedic Surgery and Traumatology, Zealand University Hospital , Køge , Denmark.; Department of Orthopaedic Surgery and Traumatology, Zealand University Hospital , Køge , Denmark.; Department of Orthopaedic Surgery and Traumatology, Zealand University Hospital , Køge , Denmark.


Background: Care continuity may have the potential to improve treatment results for patients. Additionally, educational and learning advantages for orthopedic residents can come from seeing a patient again. We found no studies that previously have described patient continuity in an orthopedic setting.
Purpose / Aim of Study: This study aimed to quantify and intervene on patient continuity for orthopedic residents in the outpatient clinic in a department with acute function.
Materials and Methods: Initially, we retrospectively analyzed consecutive outpatients in 2017 (134 patients) for the youngest residents in the Department of Orthopedics, Køge, Denmark. 8 residents then participated in an intervention campaign on improving patient continuity with a presentation at a staff meeting, followed up by reminding emails, posters and oral reminders. Afterwards we re-quantified 155 consecutive patients in early 2018 to see for an effect of our intervention. We excluded newly referred patients and no-show patients. We divided the results in 3 categories: 1) optimizable, 2) not optimizable, 3) perfect continuity.
Findings / Results: Prior to the intervention and after exclusion as described, continuity was optimizable for 35/105 (33,3%), not optimizable for 56/105 (53,3%) and perfect for 14/105 (13,3%). Post-intervention numbers were after exclusions: 41/123 (33,3%), 72/123 (58,5%) and 10/123 (8,1%). The invention did not significantly improve the proportion of perfect continuity (p=0,20) after exclusion.
Conclusions: Our intervention campaign did not significantly improve outpatient continuity for the orthopedic residents. Future efforts to improve continuity should likely focus on other factors such as residents duty schedule to influence the continuity of care.

Ane Simony, Emil Jesper Hansen, Stig Mindedahl Jespersen, Mikkel Østerheden Andersen
Rygkirurgisk Afdeling, Middelfart, Sygehus Lillebælt; Ortopæd kirurgisk afdeling, Bispebjerg Hospital; Ortopæd kirurgisk Afdeling, Odense Universitets Hospital; Rygkirurgisk Afdeling, Middelfart, Sygehus Lillebælt


Background: Since 2006 the Providence Night time Brace, has been used for conservative treatment of scoliosis. Previous studies comparing the outcome after full time bracing and Night time bracing, has reported comparable outcome with curves < 35°.
Purpose / Aim of Study: The aim of this study was to report the outcome after treatment in a cohort of Adolescent Idiopathic Scoliosis patients, with curves between 20-45°.
Materials and Methods: 124 patients with Adolescent idiopathic scoliosis were included in this study, diagnosed with Cobb > 20°, a remaining growth potential and no previous scoliosis treatment. Providence Night time treatment, 8 hours nightly, was initiated with a in brace correction > 70 %. Treatment was continued until 2 years post menarchal menarchal for the females, and until 6 months growth arrest in boys. The patients were evaluated by standing radiographs during treatment, 6 and 12 months after termination.
Findings / Results: 124 patients were included, and 80 patients terminated brace treatment and follow up. Mean inbrace correction was 83 %, and curve progression was observed in 9 patients. Brace treatment was success full in 88.7 % of patients, also in patients with curves > 35° when treatment was initiated. 5 % of the patients were referred to surgical treatment due to progression.
Conclusions: Providence night time braces are effective, as a treatment in adolescent idiopathic scoliosis patients. This study reports a success rate of 88.7 % and the results are comparable to fulltime treatment with Boston braces or other TLSO.

Mads Terndrup, Jonas Fredriksen, Catarina Malmberg, Andersen Troelsen, Ilija Ban, Peter Toft Tengberg
Department of Orthopedics, Copenhagen University Hospital Hvidovre ; Department of Orthopedics, Copenhagen University Hospital Hvidovre ; Department of Orthopedics, Copenhagen University Hospital Hvidovre ; Department of Orthopedics, Copenhagen University Hospital Hvidovre ; Department of Orthopedics, Copenhagen University Hospital Hvidovre ; Department of Orthopedics, Copenhagen University Hospital Hvidovre


Background: Indication for fixation of the syndesmosis is intraoperative instability. Complication rates are reported to be high. Suture button technique is gaining popularity and the incidence of syndesmotic fixation could be reduced with posterior malleolar fixation
Purpose / Aim of Study: To examine complication rates after osteosynthesis of ankle fractures involving fixation of the syndesmosis
Materials and Methods: Adult patients with ankle fractures treated surgically from June 2011 to December 2015 at our institution were assessed for eligibility. Exclusion criteria were: non-Danish citizen, non-operative treatment, treatment >4 weeks after injury or staged procedures, follow-up at an alternative institution, and patients lost to follow-up. Demographics and injury-related risk factors, as well as procedural data, were recorded and fractures were classified from standard radiographs and, if present, CT-scans. Postoperative data included immobilization regime, access to physiotherapy, complications, unplanned reoperation, and implant removal. Minimum follow-up was 18 months
Findings / Results: 186 (24.3%) of 764 patients eligible for review received syndesmodesis. 97% were fixed with 1-2 syndesmotic screws. 94 patients (50%) had fractures involving the posterior malleolus. 70% of patients presented with Weber C type fractures. 35 patients (19%) were fixed using 1-2 screws alone. 98% of patients were not allowed to fully weight bear from day one. 36 patients (19%) suffered complications leading to reoperation in 20 cases (11%). 82 patients (44%) required implant removal
Conclusions: Complication and reoperation rates after fixation of the syndesmosis seem high. Stability can often be achieved with posterior malleolar fixation. Optimal fixation technique, as well as standardization of intraoperative testing, should be the focus of future prospective studies

Jonas Frederiksen, Catarina Malmberg, Ilija Ban, Peter Toft Tengberg, Mads Terndrup
Department of Orthopedics, Copenhagen University Hospital Hvidovre ; Department of Orthopedics, Copenhagen University Hospital Hvidovre ; Department of Orthopedics, Copenhagen University Hospital Hvidovre ; Department of Orthopedics, Copenhagen University Hospital Hvidovre ; Department of Orthopedics, Copenhagen University Hospital Hvidovre


Background: Indications for operative treatment of unimalleolar Weber B type fracture have been based on predictions of potential instability and risk of arthritis. These injuries could however also be interpreted as potentially stable
Purpose / Aim of Study: To examine risk factors and complication rates after osteosynthesis of lateral unimalleolar Weber B type fractures (AO44B1)
Materials and Methods: Adult patients with ankle fractures treated surgically from June 2011 to December 2015 at our institution were assessed for eligibility. Exclusion criteria were: non-Danish citizen, non-operative treatment, treatment >4 weeks after injury or staged procedures, follow-up at an alternative institution, and patients lost to follow-up. Demographics and injury-related risk factors, as well as procedural data, were recorded and fractures were classified from standard radiographs and, if present, CT-scans. Postoperative data included immobilization regime, access to physiotherapy, complications, unplanned reoperation, and implant removal. Minimum follow-up was 18 months
Findings / Results: 764 patients were reviewed. 113 patients had unimalleolar Weber B fractures without talar shift on initial radiographs and were classified as AO44B1. Direct lateral approach was chosen in 96% of cases, with semitubular plate and lag screw being the preferable fixation technique (87%). Syndesmotic fixation was found indicated in 5 patients. 51 patients (45%) were not allowed to fully weight bear from day one. 17 patients (15%) suffered complications. 7 patients(6.2%) required reoperation within the first year and 27.4% needed to have the implants removed
Conclusions: ORIF of AO44B1 fractures is not without risk. We propose that AO44B1 fractures could be viewed as potentially stable and thus initially managed non-operatively. Prospective study designs should lead further investigation

christian wong, Jan Nielsen, Thomas Andersen
dept of orthopedics, hvidovre hospital; , Bandagist Jan Nielsen A/S; Dept of Orthopedics, Rigshospitalet


Background: The bracing of today are constructed to correct the frontal plane deformity of idiopathic adolescent scoliosis (AIS). The Spinaposture brace is a lighter proprioceptive soft-fabric brace to enhance rotational axial stability of the spine by inducing a kyphosing correction in frontal plane for smaller curve AIS.
Purpose / Aim of Study: The aim of this study was to evaluate the efficacy of the Spinaposture brace in the management of AIS.
Materials and Methods: Eleven patients with AIS were treated with Spinaposture brace with an initial average Cobb angle (CA) of 18.4 dg. (degrees) and no previous brace treatment. Firstly, the initial radiographic examination was in both anterioposterior (AP) and lateral projection with and without the brace for selected patients. Secondly, patients were followed prospective with AP radiographs with an interval of 3-6 months during their brace usage with an average of 15.9 months or until skeletal maturity.
Findings / Results: The initial correction in the brace was a 18 % decrease of CA in the AP plane and a kyphosing effect of 23 % in the sagittal plane. In the prospective follow-up 7 patients improved, 6 patients regressed to less than 10 degrees of CA, 2 were unchanged and 2 progressed. The average improvement was 5.1 dg. of CA. In blinded evaluation by two raters, there were good interobserver variation (ICC; 0.85), and there was significance better outcomes by statistical binominal analysis in comparison with natural history (.000).
Conclusions: The Spinaposture brace have an initial correcting of CA and kyphosing effect, which seems to improve CA. Conservative treatment with Spinaposture was effective in halting scoliosis progression in this first pilot study. For the majority of AIS with a CA of 13-25 degrees the spine decreased in CA and 5ven regressed to straight spines.

Line Marker, Mads Okholm, Peter Schjerling, Michael Krogsgaard
Institute of Sports Medicine, Bispebjerg Hospital; Intstitue of Sports Traumatology, Bispebjerg Hospital; Institue of Sports Medicine, Bispebjerg Hospital; Intstitue of Sports Traumatology, Bispebjerg Hospital


Background: Primary frozen shoulder is a painful condition with a decreased range of motion making the disease debilitating. The condition can be divided in to three phases that differs in clinical presentation. Macroscopically changes have shown contracture and fibrosis in the shoulder. Type I and III collagen has been the main investigating target so fare, and both have seen to be increased in the capsule and the surrounding ligaments.
Purpose / Aim of Study: The aim of this study was to investigate the expression of different types of collagens in patients with primary frozen shoulder, and to see if there was any difference in the expression of collagen between the three phases of idiopathic frozen shoulder.
Materials and Methods: This study used a case-control study design, analyzing patients undergoing arthroscopic treatment of iprimary FS and control patients being treated for subacromial impingement. Biopsies were taken from the medial glenohumeral ligament and the anterior capsule from all subjects. mRNA levels were analyzed using real-time PCR. Nonparametric test were used for the statistics.
Findings / Results: The results from this current study show that many genes for different types of collagens, e.g. type 1, 3, 4, 5, 6, 14, are activated in primary FS in the anterior capsule and the medial glonohumeral ligament. We also saw that there are no significant differences in the expression of collagen mRNA between the three phases.
Conclusions: Our findings suggest that there is a general increased synthesis of collagens in all phases of primary frozen shoulder, and therefore that the progression in the clinical presentation of frozen shoulder is not due to changes in collagen production.

Nicolai Kjældgaard Kristensen, Polina Martinkevich, Steffan Tábori-Jensen, stig Jacobsen, Jeppe Barckman
Orthopedics, Aarhus university Hospital; Orthopedics, Aarhus University Hospital; University Clinic for Hand, Hip and Knee Surgery, Hospital Unit West, Holstebro, Denmark ; Orthopedics, Aarhus University Hospital; Orthopedics, Aarhus university Hospital


Background: The discussion of whether hemiarthroplasty (HA) or total hip arthroplasty (THA) should be offered as treatment for displaced femoral neck fractures (FNF) is still ongoing. HA is considered a less invasive procedure and with a lesser trend to dislocation but with risk of secondary acetabular erosion.To facilitate the discussion of the indications for THA and HA we need to map the type and frequency of complications related to patients treated with HA at our institution.
Purpose / Aim of Study: To retrospectively investigate the type and frequency of complications in relations to HA in patients with displaced FNF, treated at Aarhus University Hospital.
Materials and Methods: 198 patients (156 females) were operated with HA in the years 2012 and 2017. Pathological fractures were excluded and convertion from osteosynthesis to HA was included. Mean age was 83.2 years (range 57-104). Mean follow-up was 3.2 years (range 0.2-6.2). Data collection regarding year 2013 to 2016 is still ongoing.
Findings / Results: Preliminary data from 2012 and 2017 comprises 198 patients (201 hips). 27 (13.3%) had documented dementia preoperatively. 1st time dislocation was observed in 13/201 hips (6,4%), of these 6/13 (46%) had dementia. Dislocation occurred within a mean of 14,7 days (range 7-29) after surgery. All patients received bipolar and cemented HA. 12 patients underwent reoperation. 4 convertions to THA, 2 periprosthetic fractures, 4 deep infections, 2 changes of components and 1 with extraarticular cement 78 patients (39 %) had died at follow-up, of which 13 died within 30 days after the operation.
Conclusions: In with existing data we find a 1st time dislocation rate of 6.4% with a mean time of 14.7 days after HA- surgery and a 30-day mortality of 6.5%. The full data on all patients (n=648) operated between 2012-2017 will be presented at the DOS- conference.

Sten Rasmussen, Kristian Kjær Petersen, Lars Arendt-Nielsen
Department of Orthopedic Surgery, Aalborg University Hospital; Center for Sensory-Motor Interaction , Aalborg University; Center for Sensory-Motor Interaction , Aalborg University


Background: Animal studies indicate gold ions have a long-acting effect on OA pain. The immuno-modulatory effect of gold ions have for more than 50 years a known anti-inflammatory effect in the treatment of rheumatic arthritis. Gold ions alter the function of macrophages by inhibiting lysosomal enzymes and lowering production of pro-inflammatory cytokines inflammatory cytokines
Purpose / Aim of Study: No studies have investigated the effect of intraarticular gold micro particle implants for treatment of knee osteoarthritis in humans. The present open, pilot study aimed to investigate if gold ions have a role in treating knee osteoarthritis
Materials and Methods: A cohort of 30 patients referred for treatment of knee OA, aged ≥18years, pain ≥ 3 months, synovial effusion on MRI, and Kellgren-Lawrence OA grade 3-4 were included. Metallic gold 20 mg, 72.000 pieces, 20-40 my 40 my-meter in diameter (Berlock-Micro Micro-Implants, BMI, Goldtreat APS) were injected into the knee joint using the patient's own synovial fluid as the carrier. Outcome measures were WOMAC pain, stiffness and function, PainDetect PainDetect questionnaire, and Q Quantitative Sensory Testing (QST) ( (pressure pain threshold assessed o over the knee joint) at inclusion and a after 8 weeks.
Findings / Results: Pain and function improved in 25 of 30 patients. Womac pain decreased from 9 (6-16) to 3 (0-15), stiffness from 4 (1-8) to 2 (0-8), function from 29 (14-51) to 11 (0 51) to 11 (0-41), PainDetect from 10 (1-26) to 3 (0-19), and pain pressure thresholds increased from 598 kPa (276-1043) to 616 kPa (349-1089), all P < 0.05.
Conclusions: Intra articular gold particles may modify the synovial inflammation as a part of the sensitization in knee OA patients. Intra-articular metallic gold relieved pain and enhanced function in more than 80 % of the patients. This study suggests a basis for a future placebo controlled randomized trial in OA patients

Kappel Andreas, Nielsen Jeanette Gade, Stengaard-Pedersen Henrik, Valsted Inge-Merethe, Christensen Poul Hedevang, Simonsen Ole Højgaard
Orthopedics Aalborg/Farsø, Aalborg University Hospital; , Aalborg University Hospital; , Aalborg University Hospital; Orthopedics Farsø, Aalborg University Hospital; Orthopedics Farsø, Aalborg University Hospital; Orthopedics Aalborg/Farsø, Aalborg University Hospital


Background: Air quality in operating rooms (OR) used for joint replacement surgery should be “ultra-clean” and a maximum of 10 colony forming units/m3 (CFU) is guided.
Purpose / Aim of Study: To draw attention to the accumulation of early periprosthetic joint infection (PJI) and the coincidence of elevated CFU count in a newly commissioned OR.
Materials and Methods: Primary knee replacement at Farsø Hospital in the period from 2013 to 2017 were reviewed, re-operation within 8 weeks, were identified. Details regarding the commissioning and monitoring of the OR were collected.
Findings / Results: 19 re-operations within 8 weeks and 1982 primary knee arthroplasties were identified. 14 cases were early PJI (within 4 weeks) and 5 cases were other causes (2 “late” infections, 1 fracture, 1 patella dislocation, 1 patella ligament avulsion). Mean rate of early PJI was 0.2 cases per month corresponding to an incidence of 0.7%. In 2017 4 cases presented with early PJI within 4 weeks. Auditing revealed the only common characteristic to be surgery in the newly commissioned operating room. The OR had been used 2 weeks before the first early PJI case was operated, another technical identical room with had been used for 30 months without PJI being observed, both new rooms have turbulent air flow (TAF). OR air quality was monitored and CFU of 36 was measured in the new OR, in the identical room the CFU was 2.5. Following both cleaning and adjustments acceptable CFU counts were obtained, however CFU count are monitored monthly and remain to fluctuate between 0.8 and 8.3. No further PJI cases have been identified. Conversion of the TAF rooms to laminar flow is planned.
Conclusions: OR’s with identical technical specifications can have different air quality. Especially when commissioning OR’s surgeons must advocate and insist that air quality is monitored continuously.

Lina Holm Ingelsrud, Ewa Roos, Kirill Gromov, Anders Troelsen
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre


Background: Clinical care pathways for knee osteoarthritis (OA) are not always in line with clinical guidelines.
Purpose / Aim of Study: To investigate 1) to which degree patients receive OA information and 2) which treatments patients with knee OA have attempted prior to referral to an orthopaedic surgeon for an assessment of knee replacement.
Materials and Methods: Cross-sectional cohort study including all patients with scheduled first-time appointments for knee OA at Hvidovre outpatient orthopaedic clinic from April 2017 to February 2018. Postal questionnaires included the OsteoArthritis Quality Indicator questionnaire and questions about previous physiotherapist-delivered treatment for knee OA.
Findings / Results: Out of 660 eligible patients, 517 responded (78%). Responders’ mean age was 66 years and 62.5% were female. 128 (25%) patients had received information about OA development, 148 (29%) about possible treatment modalities, 72 (14%) about self-management and 100 (19%) about lifestyle adaptation. 247 (48%) patients felt informed about physical activity benefits, while 185 (35%) had consulted a physiotherapist due to knee problems during the past year. The physiotherapist-delivered treatments were any type of exercise therapy for 115 (26%) and participation in the Good Life with osteoArthritis in Denmark treatment concept for 62 (12%) of responding patients. Stretching was received by 45 (9%) and massage, acupuncture and ultrasound/laser was received by 48 (9%), 37 (7%) and 24 (5%) patients, respectively. Patients may have received several treatments in combination. Paracetamol was recommended as first-line pain medication to 349 (68%) patients.
Conclusions: Patients with knee OA are undertreated in primary care. Our results call for better structure and uniform pathways for primary knee OA treatment before referral to an orthopaedic surgeon.

Patrick Nyborg Butler, Josef Gorgis, Søren Overgaard, Bjarke Viberg
Syddansk Universitet SDU, Syddansk Universitet SDU; Syddansk Universitet SDU, Syddansk Universitet SDU; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital – part of Hospital , Department of Clinical Research, University of Southern Denmark


Background: When introducing new implants, surgeons undergo steep learning curves, leading to increased revision frequency. Stepwise introduction (SI) revolutionized introductions of new implants, but lacked a last step. No guidelines exist for introductions of new well- documented implants not previously used in a department. This is a problem according to the EU legislated tendering process, potentially leading to disasters such as metal-on-metal cases in total hip arthroplasty (THA). In this systematic review, the introduction of new, well- documented THA implants to experienced surgeons are investigated concerning higher revision frequency.
Purpose / Aim of Study: Are the introductions of new, well-documented implants to experienced surgeons associated with higher revision frequency for patients with OA undergoing primary THA?
Materials and Methods: A systematic literature search was conducted in Embase & Medline. Covidence software was then used by two reviewers to screen title/abstract and subsequently full text for inclusion.
Findings / Results: No articles were found fulfilling our eligibility criteria. A post hoc analysis retrieved two national register- based studies only missing information of the surgeon’s knowledge of the introduced implant. None of the introduced implants decreased revision frequency and around 30% of the introduced implants were associated with a higher revision frequency.
Conclusions: The current management of learning curve, in relation to these introductions, need guidelines to minimize revision frequency. An expansion of (SI) with a fourth clinical step might decrease revision frequency. This would be possible by avoiding the continuation use of worse performing implants than the ones already used. Finally, EU Legislation concerning introductions would need to move more towards the regulations of the pharmacological regime.

Marie Bagger Bohn, Bent Lund, Jeppe Lange
Orthopedic, Regions Hospitalet Horsens; Orthopedic, Regions Hospitalet Horsens; Orthopedic, Regions Hospitalet Horsens


Background: Lateral hip pain (LHP) represents a diagnostic and treatment challenge. Each year more than 1200 patients are diagnosed with LHP in the Central Region Denmark. Internationally, there has been an increased attention on gluteus medius (GM) tendon tears and tendinopathies as the cause of LHP. It has been estimated that GM injuries may be present in as many as 25% of middle-aged women and 10% of middle-aged men. Yet, protocolled diagnostic and treatment regimens are not well established and there is a pronounced lack of general knowledge on GM injury as the cause of LHP.
Purpose / Aim of Study: To evaluate a series of patients with LHP due to GM injury diagnosed via MRI scans.
Materials and Methods: From September 2017 - May 2018 data on patients with LHP due to GM injury were prospectively collected at Regional Hospital Horsens. Clinical tests, subjective outcome measures and MRI scans were used to identify and assess patients. Patients with positive MRI scans for GM injury were included in this evaluation.
Findings / Results: We evaluated 33 patients (28 women), with a mean age of 52.5 years (range 16- 80 years). Mean duration of symptoms was 55 months (range 5-240 months) prior to our diagnosis. The HAGOS score was S: 45 ± 19, P: 52 ± 19, ADL: 45 ± 26, SP: 32 ± 21, PA: 19 ± 18, QOL: 25 ±14. OHS score 27 ± 8.5. VAS score: at rest: 2.9 (0-7), during activity: 5.9 (0-10) and worst pain 8.3 (5-10).
Conclusions: GM injury must be considered as a cause of LHP, especially if the pain is resistant to injection with corticosteroid in the trochanteric bursa. The vast majority of our patients had LHP for many years and tried numerous corticosteroid injections. We found that a dedicated MRI protocol could reveal GM injury. Baseline HAGOS and VAS scores of patients with LHP due to GM injuries are poor.

Jacob Korsbæk Rasmussen, Lone Nikolajsen, Karen Toftdahl Bjørnholdt
Health, Aarhus University; Anaesthesiology, Aarhus University Hospital; Orthopaedic surgery, Horsens Regional Hospital


Background: Pain can be severe during the first days after arthroscopic surgery, and acute pain is an important outcome in clinical trials of surgical technique or anaesthetic strategy. A standardized, validated method of assessing acute postoperative pain would improve the quality of clinical studies, and facilitate systematic reviews and meta-analyses. A step on the way towards this standard is to investigate the methods most commonly used in recent literature.
Purpose / Aim of Study: To guide the design and execution of future clinical trials where acute postoperative pain is a relevant outcome.
Materials and Methods: Methods: PubMed and CINAHL databases were searched, including studies of arthroscopic rotator cuff surgery with a primary pain-related outcome during the first postoperative week, published in English from 2012 to 2017.
Findings / Results: A total of 47 studies were included, all measuring pain intensity using a pain rating scale. Most frequently used was the visual analogue scale using the anchors “no pain” and “worst pain imaginable”, with recordings at 1, 2, 4, 6, 8, 12, and 24 hours postoperatively. A total of 34 studies recorded analgesic consumption, usually as average cumulated consumption in mg. Time to first analgesic request or first pain were recorded in 11 studies, and 4 different starting points were used.
Conclusions: This study describes the currently most common methods of assessing acute postoperative pain in clinical trials of arthroscopic shoulder surgery involving rotator cuff repair, and the large variety of methods applied. Based on this study and international guidelines, several recommendations on how to measure and report postoperative pain outcomes in future trials are proposed.

Jeanette Trøstrup, Carsten Bogh Juhl, Lone Ramer Mikkelsen
Forskningsenheden, Center for Planlagt Kirurgi, Regionshospitalet Silkeborg, Hospitalsenhed Midt; Muskuloskeletal Funktion og Fysioterapi (FoF) Institut for Idræt og Biomekanik, SDU; Forskningsenheden, Center for Planlagt Kirurgi, Regionshospitalet Silkeborg, Hospitalsenhed Midt


Background: Patients with musculoskeletal diseases referred to an outpatient orthopaedic clinic can potentially be assessed by an extended scope physiotherapist (ESP) instead of an orthopaedic surgeon (OS).
Purpose / Aim of Study: To evaluate the diagnostic accuracy, cost and patient satisfaction of the musculoskeletal assessment performed by ESP compared to OS.
Materials and Methods: MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, PEDro and reference lists of included studies and previous reviews were searched in November 2015. Studies were included if they 1) evaluated adults with a musculoskeletal disease referred to an outpatient orthopaedic clinic where a diagnostic assessment had been conducted by an ESP and 2) evaluated one of our primary (diagnostic agreement, costs and satisfaction) or secondary outcomes (wait time and relevant referrals). Data were extracted using a customised data extraction sheet. Two reviewers independently evaluated the methodological quality using checklists, and classified risk of bias in high, moderate and low.
Findings / Results: We included one randomised controlled trial and 31 observational studies. Diagnostic agreement between ESPs and OSs ranged from 65 to 100% across studies. Health care cost savings for diagnostic assessments performed by ESPs were between 27 and 49% compared to OSs. Overall, between 77 and 100% of the patients were satisfied with the ESP assessment.
Conclusions: Diagnostic assessments performed by ESP may be at least as beneficial than assessment performed by OSs in terms diagnostic agreement, costs and satisfaction. However, the methodological quality of included studies was generally too low to determine the clear effectiveness of ESP assessment, and more high quality studies are needed.

Dhia Al-Fadli, Søren Peter Eiskjær, Peter Doering, Peter Heide Pedersen , Jon Kaspersen
Orthopaedi, Aalborg University Hospital ; Orthopaedi, Aalborg University Hospital ; Orthopaedi, Aalborg University Hospital ; Orthopaedi, Aalborg University Hospital ; Orthopaedi, Aalborg University Hospital


Background: Pelvic fractures pose a complex problem with a number of possible treatment modalities. Traditionally fractures involving the acetabular region of the pelvis have been treated with open reduction and internal fixation (ORIF) or total hip arthroplasty. (THA). However, ORIF and primary hip arthroplasty are major surgeries not always well tolerated in the elderly and frail. We present an alternative minimally invasive method for pelvic fracture fixation
Purpose / Aim of Study: To evaluate short- and long-term clinical outcome in patients operated with percutaneous cannulated “superior ramus screw” (SRS) for instable anterior column pelvic fractures
Materials and Methods: Retrospectively 16 patients operated in the years 2007-2014 with SRS were identified and classified according to the Nakatani system. All patients had single or bilateral minimally invasive cannulated screw fixation. Intraoperative CT scans were performed to ensure correct screw positioning. The operative results were evaluated with the EQ-5D-3L and the Merle d'Aubigné Questionnaires
Findings / Results: Six patients were lost to clinical follow- up. Mean follow-up was 24 months (range: 12-120 months). Mean age was 57 years (range 19-75). Three non-reducible acetabular fractures were later converted to THA – fishers test: p = 0,008. Merle d’Aubigné registered an absolute score (mean) of 9 corresponding to a satisfactory result and EQ-5D-3L utility value gave a mean of 0,75(which is better than 1 year after hip fracture). The screws were all placed correctly (CT). Besides conversion to THA, no complications (including neurovascular injury) were registered
Conclusions: Percutaneous SRS fixation presents a possible alternative for fixation of acetabular fractures in the elderly and frail with no serious complications

Michelle Fog Andersen, Anton Mitchell Ulstrup
Department of Orthopaedic Surgery, Holbæk Hospital; Department of Orthopaedic Surgery, Holbæk Hospital


Background: A satisfying functional result in the treatment of adult humeral shaft fractures with locked intramedullary nailing entails preserved function of the radial nerve. It is found worth investigating the risk of radial nerve injury when a long nail is introduced into a humeral shaft fracture without surgical radial nerve exploration.
Purpose / Aim of Study: To retrospectively examine the outcome of intraoperative radial nerve lesions following humeral shaft fixation with locked long intramedullary nailing without nerve exploration.
Materials and Methods: Between 2007 and 2016, 89 patients with no preoperative nerve lesion were treated for a displaced humeral shaft fracture with a locked long intramedullary nail performed in five centres in Region Zealand. All motoric radial nerve lesions were registered and followed up in medical records until treatment of the patient ended.
Findings / Results: 85 out of 89 patients (mean age; 67 years) were available for an outpatient follow-up. 72 fractures were non-pathological and of these, 31 were nonunions. 28 and 61 were identified in the proximal and middle thirds of the humeral shaft. In total, 9% (8/89) developed immediate postoperative radial nerve palsies. The risk of a radial nerve palsy was 7.9% (6/76) for closed nailing and 15.4% (2/13) for nailing involving open surgery in the fracture area. Of these, the risk was 33% (2/6) for nailing with a nerve exploration. 1 patient sustained a verifiable permanent radial nerve paralysis. Associations of a postoperative radial nerve palsy were mid-shaft fractures, female gender and surgery for nonunion fractures.
Conclusions: Our results indicate that exploration of the radial nerve is not necessary routinely in order to prevent radial nerve lesions when performing closed nailing for humeral shaft fractures in adults with a preoperative normal radial nerve function.

Lisa C. U. Reimer, Julie S. Jacobsen, Inger Mechlenburg
Orthopedics, Aarhus University Hospital; Physiotherapy, Faculty of Health Sciences, VIA University College; Clinical Medicine, Aarhus University


Background: Greater Trochanteric Pain Syndrome (GTPS) is a common and disabling hip condition. Hypermobility has been suggested as a possible cause of GTPS. The purpose of this study was to report the prevalence of hypermobility and to investigate its impact on hip-related function and awareness in patients with GTPS.
Purpose / Aim of Study: The primary aim of this study was to report prevalence of GJH and investigate the impact of GJH on self-reported outcome in patients 2-4 years after initial diagnosis with GTPS.
Materials and Methods: This cross-sectional study was based on a cohort of patients diagnosed with GTPS in the period 2013- 2015. Hypermobility was investigated with the Beighton score and defined by a cutoff score ≥5. Patients' current hip function and awareness was collected with the questionnaires the Copenhagen Hip and Groin Outcome Score and the Forgotten Joint Score.
Findings / Results: 612 patients with GTPS were identified based on the diagnosis-system and out of these 145 (37%) were included. The prevalence of hypermobility within this cohort was estimated to be 11% (95% CI: 3;26) for males and 25% (95% CI:17;34) for females. No significant association was found between hypermobility and self-reported hip function and awareness.
Conclusions: The prevalence of hypermobility in patients with GTPS was high but the prevalence of hypermobility did not influence hip function and awareness. The results were based on a very low response rate and should be interpreted with this in mind.

Uggi Balle, Christian Færgemann
Department of Orthopaedic surgery, Odense University Hospital; Department of Orthopaedic surgery, Odense University Hospital


Background: Despite routinely screening of all new-borns in DK late-presenting developmental dysplasia of the hip (DDH) with hip dislocation is still a relatively frequent diagnosis.
Purpose / Aim of Study: To examine the causes of missed diagnosis in infants with DDH with dislocation.
Materials and Methods: A retrospective study of all children with hip dislocation due to late-presentation dysplasia of the hip (defined as diagnosis after 3 months of age) treated at Odense University Hospital 2015-17. Data was extracted from the patient registration system.
Findings / Results: Overall 16 infants were diagnosed with late-presenting DDH with dislocation in the study period. One child had bilateral dislocations. All infants had routinely postpartum screening made by either a trained midwife or a paediatrician. Nine infants were referred by their GP, 4 by a paediatric specialist, and 3 by an orthopaedic surgeon. Only two infants had known disposing factor (breech presentation and family history of hip dysplasia). The median age at diagnosis was 1.2 year (range: 0.3-2.6). One infant with bilateral hip dislocation and waddling gait was ignored by the GP and finally referred at the age 1.6 years. Another infant was examined by the GP several times without taking any action although the child had been limping since she started walking. The dislocation was diagnosed at the age of 2.6 years. One patient was continuously examined with ultrasound until an x-ray revealed the dislocation at age 0.9 years. One infant was examined by an orthopaedic surgeon at age 125 days without diagnosing the dislocation. The dislocation was diagnosed at age 2.3 years.
Conclusions: Few infants with hip dislocation had known risk factors. Missing of the diagnosis occurs at all levels of the referral chain. Limping at walking debut should be taken seriously either risk factors of DDH or not.

Kelwin Perez Contreras, Søren Fruensgaard, Sasa Randelovich, Gang Chen, Peter Lemche, Carsten Ernst, Thomas Bender, Malene Laursen
Spine Unit, Regional Hospital Silkeborg; Spine Unit, Regional Hospital Silkeborg; Spine Unit, Regional Hospital Silkeborg; Spine Unit, Regional Hospital Silkeborg; Spine Unit, Regional Hospital Silkeborg; Spine Unit, Regional Hospital Silkeborg; Spine Unit, Regional Hospital Silkeborg; Spine Unit, Regional Hospital Silkeborg


Background: The minimally invasive spine surgery fusions techniques are been used world wide, have been suggested as a safe alternative to open surgery without higher complication rates. In our center, this techniques were used until 2017. We found some complications in our outpatient, and we decided to do this retrospective study with all the 150 patients.
Purpose / Aim of Study: The purpose of the current investigation was to evaluate safety and efficacy regarding minimally invasive techniques, i.e., transforaminal lumbar interbody fusion (MIS TLIF) and posterolateral lumbar fusion (MIS PLF) in a selected Danish population.
Materials and Methods: Consecutive patients undertaking MIS TLIF and MIS PLF in CPK, Silkeborg in the period 2011 - 2017. Data were collected retrospectively from local hospital records with the help of all surgeons in the spine unit. Outcome measures were complication-rate duringadmission and post discharge according to number of fusion levels and a BMI discrimination between the normal and obese patient.
Findings / Results: MIS TLIF: n= 67 patients. M/F: 29/38. Median age 42 yr. [25-70]. Complications: nerve injury (1), neuropraxi (1). screw-breakage (1), Superficial Infection (1), Cage migration (1). Revision surgery: 4 decompression and 3 implant removeal and refusion MIS PLF: n=83 patients. M/F: 36/47. Median age 46 yr. [20-75] Complications: subcutaneous hematoma (1), Pedicle fracture (1). screw-breakage (4), screw-loosening (5), Both screw breakage and loosening (1), rod-breakage (1). Revision surgery: 5 decompression and 11 implant removeal and refusion
Conclusions: The results indicate that one-level MIS TLIF might be a safe in a selected group of patients. MIS PLF technique reveals a high mechanical failure rate, the complication and -reoperation rate was higher in the obese patients.

Simon Toftgaard Skov, Jan H.D. Rölfing, Haisheng Li, Kestutis Valancius, Kristian Høy, Ebbe Stender Hansen, Peter Helmig, Cody Bünger
Dep. of Orthopaedic Surgery, Aarhus University Hospital; Dep. of Orthopaedic Surgery, Aarhus University Hospital; Dep. of Orthopaedic Surgery, Aarhus University Hospital; Dep. of Orthopaedic Surgery, Aarhus University Hospital; Dep. of Orthopaedic Surgery, Aarhus University Hospital; Dep. of Orthopaedic Surgery, Aarhus University Hospital; Dep. of Orthopaedic Surgery, Aarhus University Hospital; Dep. of Orthopaedic Surgery, Aarhus University Hospital


Background: The use of magnetically controlled growing- rods (MCGR) is considered by many to be a major evolution in the surgical management of early-onset scoliosis (EOS). Because MCGR treatment entails high initial costs (i.e. implant costs), financing it under the auspices of a public health care system may prove challenging.
Purpose / Aim of Study: The aim of the study is to investigate whether EOS patients and their next of kin experience the MCGR lengthening procedures as psychologically and physically stressful as well as their satisfaction and pain in conjunction with the procedure.
Materials and Methods: A cross-sectional study of 19 EOS patients, median age 11(range 7-17) years, with MCGR implantation between 2014 and 2017. All patients had undergone unsedated MCGR distraction at three months intervals. The parents answered a seven-item MCGR Satisfaction Questionnaire. The answers were scored on a 0-10 Likert scale.
Findings / Results: The median (range) questionnaire response to the seven-item questionnaire was: 0(0-5) for physical strain on the patient, 0(0-7) for psychological strain on the patient, 1(0-2) regarding pain, and 0(0-5) regarding anxiety level of the parents. The median satisfaction with the MCGR treatment was 10(8-10) [0 very dissatisfied, 10 very satisfied], and the median likelihood of requesting MCGR if they were to repeat surgery was also 10(9-10) [0 no preference regarding method, 10 highest preference for MCGR].
Conclusions: Overall satisfaction with MCGR was uniformly high to very high. If given the choice, five out of five parents with previous experience with other growth instrumentation would choose MCGR in preference over other growth instrumentation. Both the physical and psychological strain and pain in conjunction with the unsedated lengthening procedure were low.

Jan Duedal Rölfing, Arnar Oskar Bjarnison, Anne Stensbjerg, Juozas Petruskevicius
Traumatology and Reconstructive Surgery Unit, Department of Orthopaedics, Aarhus University Hospital; Traumatology and Reconstructive Surgery Unit, Department of Orthopaedics, Aarhus University Hospital; Traumatology and Reconstructive Surgery Unit, Department of Orthopaedics, Aarhus University Hospital; Traumatology and Reconstructive Surgery Unit, Department of Orthopaedics, Aarhus University Hospital


Background: Superficial pinsite infection is common in ring fixation in trauma, limb lengthening and deformity surgery. Checketts and Otterburn (CO) suggest classification in type CO1-3 minor infections necessitating improved pinsite care, oral antibiotics, and wire/pin removal, respectively; and in type CO4- 6 major infections calling for abandonment of the frame.
Purpose / Aim of Study: We developed a paper-based registration tool in order to: (1) evaluate pinsite infections prospectively and (2) provide a concise overview over the frame’s history incl. operations and infections.
Materials and Methods: Prospective cohort study evaluating pinsite infection and feasibility of the novel tool in 19 trauma and limb deformity patients (pts.) treated with a tibia ring fixator extending to the femur in 3 and foot in 4 cases. Median age: 56 (12-88) years; median follow-up from surgery: 41 (13-169) days; 11 ♂ : 8 ♀.
Findings / Results: 9/19 pts. were infected: 6 pts. CO1-2 requiring oral antibiotics, 2 pts. CO3 demanding wire removal/replacement and 1 pt. CO5 resulting in amputation. The median age of infected and uninfected patients was 65 vs. 51 years (p=0.4). All femur rings had CO1-2. In the tibia infection was predominantly localized at wires in the proximal 25% rather than wires or half pins elsewhere (p<0.05). Interestingly, nearly no infections were recorded close to the ankle or foot plate. The tool was deemed feasible and easy to use. Especially the instant and concise overview of the frame’s history including all operations and infection was highly appreciated.
Conclusions: We report pinsite infection rates in ring fixation consisted with the extant literature. The registration tool helped to ease communication and workflow in the outpatient clinic and to choose the treatment protocol by providing an overview of pinsite status, use of antibiotics and operations.

Camilla Mersø, Martin Gottliebsen
, Hvidovre Hospital ; , Aarhus Universitetshospital


Background: Septisk artrit hos børn er en tilstand med bakteriel infektion i hofteleddet. Særligt hvad angår mistænkt infektion i hofteleddet, kan det være svært på afdelinger med hovedfunktionsniveau, at foretage fx kirurgisk drænage. Aspiration af leddet er en mindre omfattende procedure, og arbejdsgruppen fandt det derfor relevant, at afdække om aspiration af leddet kan stå alene som procedure.
Purpose / Aim of Study: Bør børn med mistænkt septisk artrit i hofteleddet behandles primært med åben drænage (fenestrering af ledkapslen) eller er aspiration (isoleret eller gentagne) sufficient?
Materials and Methods: Gennemgang af den litteratur
Findings / Results: Vi kan, ved gennemgang af den litteratur der er fremkommet ved ovennævnte søgning, ikke finde grundlag for en generel anbefaling af åben drænage af hofteleddet over for artrocentese (evt gentaget og evt skylning på kanyle) ved septisk artrit. Litteraturen på området er generelt på et lavt evidensniveau og består primært at retrospektive opgørelser. Der forefindes ikke RCT eller Cochrane reviews. Det bør nævnes at et gennemgående tema i flere nyere opgørelser er, at mange tilfælde af septisk artrit i hofteleddet hos børn, kan håndteres med aspiration alene. Flere artikler beskriver forsigtighed ved neonatal septisk artritis i hofteleddet og at behovet for åben drænage kan være større her.
Conclusions: Det er ikke muligt at give en anbefaling på det valgte PICO spørgsmål. Det må dog anses for god praksis ved mistanke om septisk artrit i hofteled på børn altid som minimum at foretage akut punktur med udtømning og skylning af leddet eller akut overflytte barnet til børneortopædisk specialafdeling. Videre behandling bør varetages af børneortopædisk specialafdeling der kan varetage yderligere diagnostik og behandling.