Session 19: Foot / Ankle
Fredag d. 26. oktober
13:00-14:30
Lokale: Helsinki/Oslo
Chairmen: Marianne Vestermark og Kristian Kibak Nielsen
149. Acute Achilles tendon rupture - The influence of gender and age on treatment outcome. A registry study from the Danish Achilles tendon Database.
Allan Cramer, Nanna Cecilie Jacobsen, Maria Swennergren Hansen, Håkon Sandholdt, Per Hölmich, Kristoffer Weisskirchner Barfod
Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre; Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre; Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Amager-Hvidovre; Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital, Amager-Hvidovre; Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre; Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre
Background: Studies suggest that women have worse treatment
outcome than men after acute Achilles tendon
rupture (ATR). The combined influence of age and
gender remains unexplored in the literature. Studies
with large sample size including a sound number of
women are needed to further investigate this.
Purpose / Aim of Study: To investigate if gender and age affect patient
reported and functional outcome following ATR.
Materials and Methods: The study was performed as a registry study in the
Danish Achilles tendon Database. The endpoints
were the Achilles tendon Total Rupture Score
(ATRS) at 4 months, 1 year and 2 years after injury,
heel-rise height (HRH) and Achilles tendon resting
angle (ATRA) at 4 months, and return to same type
of work and sport at 1 and 2 years.
Findings / Results: Data were collected from April 2012 to March 2018.
1524 patients participated at 4 months, 1277 at 1
year and 899 at 2 years. Women scored mean (CI)
4.8 (1.8;7.8) points lower in ATRS than men at 4
months (p<0.01), 9.9 (4.3;15.5) at 1 year (p<0.01)
and 3.6 (-3.1;10.2) at 2 years (p=0.30). No
statistically significant differences were found
between gender in HRH and ATRA. Age showed a
weak correlation to ATRS at 1 year (r=0.12), but not
at 4 months and 2 years. Operated and non-
operated patients showed no statistically significant
differences in treatment outcomes.
Conclusions: Women scored statistically significantly less than
men in ATRS at 4 months and 1 year after ATR, but
not after 2 years. The difference was less than half
the clinically relevant difference at 4 months and
peaked at 1 year where it equaled the clinically
relevant difference. The functional outcomes did not
reflect the difference at 4 months. Age did not seem
to influence the outcome after ATR.
150. Individual treatment selection for acute Achilles tendon rupture based on the Copenhagen Achilles Length Measure (CALM)
Kristoffer W. Barfod, Maria S Hansen, Håkon Sandholdt, Anders Boesen, Per Holmich, Anders Troelsen, Morten T Kristensen
Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre; Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C),Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Amager-Hvidovre; Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre; Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre; Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre; Clinical Orthopedic Research Hvidovre (CORH), Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre; Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C),Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Amager-Hvidovre
Background: An evidence based selection tool is needed to guide
choice of treatment after acute Achilles tendon
rupture (ATR).
Purpose / Aim of Study: To investigate if the 1-year outcome of patients with
ATR can be predicted by Amlang’s ultrasound
classification (AmC) or the Copenhagen Achilles
Length Measure (CALM).
Materials and Methods: The study was conducted as a prospective
cohort study on patients included in an RCT
(identifier: NCT02015364). Patients were 18 to
70 years, treated non-operatively and allocated
to either early controlled motion of the ankle or
immobilization. AmC and CALM were assessed
within 4 days of rupture and correlated to
outcomes at 1 year. The primary outcome was
the Achilles tendon Total Rupture Score (ATRS).
Secondary outcomes were: heel-rise-work test
(HRW), re-rupture rate (RR) and CALM at 1 year.
To define a cut-off for AmC and CALM at
baseline ROC analysis was performed for
measures that correlated statistically significantly
to outcomes. Acceptable elongation at 1 year
was defined as 10%.
Findings / Results: From February 2014 to December 2016 CALM was
assessed at baseline in 130 patients and AmC in
109. AmC showed no statistically significant
correlation to any of the outcomes. CALM at
baseline showed no significant correlation with
ATRS, HRW or RR, but with CALM (r=0.214,
p<0.01), at 1 year.
The ROC model had AUC = 0.67. An elongation of
7% at baseline had a sensitivity of 0.77 and
specificity of 0.50.
Conclusions: Elongation of the Achilles tendon at baseline
measured with CALM showed a weak positive
correlation to CALM at 1 year suggesting that CALM
at base line has some but limited ability in predicting
elongation at one year. A cut-off of 7% elongation at
baseline correctly identified 77% of patients with an
elongation above 10% at 1 year, but also identified
50% of patients without elongation at 1 year.
151. Acute Achilles tendon rupture - The influence of comorbidity on patient reported and functional outcome. A registry study from the Danish Achilles tendon Database.
Nanna Jacobsen, Allan Cramer, Maria Swennergren Hansen, Håkon Sandholdt, Per Hölmich, Kristoffer Weisskirchner Barfod
Sports Orthopedic Research Center - Copenhagen (SORC-C), Copenhagen University Hospital, Amager-Hvidovre Denmark; Sports Orthopedic Research Center - Copenhagen (SORC-C), Copenhagen University Hospital, Amager-Hvidovre Denmark; Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Amager-Hvidovre Denmark; , Copenhagen University Hospital, Amager-Hvidovre Denmark; Sports Orthopedic Research Center - Copenhagen (SORC-C), Copenhagen University Hospital, Amager-Hvidovre Denmark; Sports Orthopedic Research Center - Copenhagen (SORC-C), Copenhagen University Hospital, Amager-Hvidovre Denmark
Background: Little is known concerning the influence of
comorbidity on outcome after acute Achilles
tendon rupture (ATR). The Danish Achilles
tendon Database prospectively collects data
on patients with ATR from 11 hospitals in
Denmark.
Purpose / Aim of Study: To investigate if comorbidity and previous
Achilles tendon disorders affect patient
reported and functional outcome after ATR.
Materials and Methods: The study was conducted as a registry
study based on data from the Danish
Achilles tendon Database (DADB) in the
period from April 2012 to March 2018.
Outcomes were the patient reported
outcome Achilles Tendon Rupture Score
(ATRS) evaluated 4, 12 and 24 months after
injury, and the indirect measures of tendon
elongation the Achilles tendon resting angle
(ATRA) and heel-rise height (HRH)
evaluated at 4 months. Variables of interest
were diabetes, hypertension, rheumatic
disease, smoking and previous Achilles
tendon disorder. Stepwise multiple
regression analysis with backwards
elimination was performed.
Findings / Results: 1060 patients with full dataset were
available at 4 months, 525 at 12 months
and 410 at 24 months. Hypertension was
statistically significantly correlated to ATRA
at 4 months, r=0.10 (p<0.01) and ATRS at
12 months, r=0.11 (p=0.02). Smoking was
statistically significantly correlated to HRH
at 4 months, r=0.07 (p=0.03). No other
variables were correlated to the three
outcomes.
Conclusions: None of the chosen variables showed a
convincing pattern of correlation to the three
outcome variables. Smoking and
hypertension might influence tendon
elongation as they each correlated to one of
the two indirect measurements of tendon
elongation (ATRA and HRH) at 4 months.
Furthermore, hypertension correlated to
ATRS at 12 months. Further studies are
needed to determine if smoking and
hypertension are risk factors for elongation.
152. HemiCAP for Hallux Rigidus: Good function and excellent pain relief at 5-8 year follow-up
Kristian Henrik Brink Behrndtz, Asmus Overbeck Petersen, Karen Toftdahl Bjornholdt
Orthopedic, Regional Hospital Horsens; Orthopedic, Regional Hospital Horsens; Orthopedic, Regional Hospital Horsens
Background: Hallux rigidus is osteoarthritis of the first metatarso-
phalangeal joint leading to decreased dorsiflexion
and pain, previously treated by arthrodesis. To avoid
problems of non-union, mal-union and footwear
difficulties, and to preserve some dorsiflexion,
hemiarthroplasty is now an option. However, few
medium-long-term studies have been available.
Purpose / Aim of Study: To evaluate the medium-long term results of the
Orthotech HemiCAP® implant in patients with hallux
rigidus.
Materials and Methods: A clinical prospective observational study of 31
consecutive patients (38 feet) treated with the
HemiCAP implant at Horsens Regional Hospital
from 2009-2013 were contacted and offered
evaluation by clinical examination, weight-bearing x-
rays, American Orthopaedic Foot and Ankle Society
Hallux Metatarsophalangeal-Interphalangeal Scale
(AOFAS-MTP-IP), and visual analogue scale for
pain intensity (VAS).
Findings / Results: Of the 31 patients, 23 patients (28 feet) agreed to
participate, 3 patients (5 feet) had died of unrelated
causes, and 5 patients (5 feet) did not wish to
participate. Follow-up time was 5,1-8,5 (mean 6,8)
years. No implants had been revised. The mean
dorsiflexion had improved from 15 degrees to 28
degrees. X-rays showed no signs of loosening, but
varying degrees of subsidence into the base of the
proximal phalanx. AOFAS-MTP-IP scores improved
from 52 preoperatively to 84 at follow-up. Pain
intensity decreased from 7,1 preoperatively to 1,1 at
follow-up. Of the 23 participating patients, 19 (83 %)
would choose this treatment again, 3 (13 %) would
not, and 1 (4 %) did not know.
Conclusions: Good functional results and excellent pain relief was
obtained at 5-8 years follow-up with the HemiCAP
implant for hallux rigidus. No revisions or
radiographic loosening were seen, but varying
subsidence into the base of the proximal phalanx
was observed.
153. Validation of the Achilles Tendon Length Measure and the Achilles Tendon Resting Angle in relation to the Copenhagen Achilles Length Measure
Maria Swennergren Hansen, Morten Tange Kristensen, Per Hölmich, Kristoffer W. Barfod
Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C),Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Amager-Hvidovre; Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C),Department of Physiotherapy and Occupational Therapy and Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre; Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre; Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre
Background: Elongation of the Achilles tendon after
rupture is a frequent and overlooked
complication. The Achilles Tendon
Length Measure (ATLM) and the
Achilles Tendon Resting Angle (ATRA)
are indirect length measures using the
resting angle of the ankle.
Copenhagen Achilles Length Measure
(CALM) is a direct ultrasound
measure. To examine the influence of
elongation valid clinical measures of
the length of the Achilles tendon are
needed.
Purpose / Aim of Study: To examine the concurrent validity of
ATLM and ATRA in relation to CALM.
Materials and Methods: The study was performed as a validity
study. Data were gathered from
patients included in a randomized
controlled trial from February 2014 to
December 2016. All patients were
treated non-operatively with early
controlled weight-bearing. Comparison
between measures was performed
using Pearson’s correlation at 2, 4, 6
and 12 months after injury.
Findings / Results: 84 patients were included (18 women,
66 men), mean (SD) age 42.4 (11.2)
years. The correlations between CALM
and ATRA were 0.244 (p=0.03) at 2
months, 0.159 (p=0.15) at 4 months,
0.063 (p=0.57) at 6 months and 0.191
(p=0.08) at 12 months. Corresponding
data between CALM and ATLM were
0.319 (p<0.01), 0.263 (p=0.02), 0.036
(p=0.74), 0.132 (p=0.23) and between
ATRA and ATLM 0.633 (p<0.01),
0.461 (p<0.01), 0.463 (p<0.01), 0.476
(p<0.01).
Conclusions: A very weak to weak positive
correlation was found between CALM
and ATRA/ATLM indicating that the
two indirect measures does not
measure the same construct as the
direct ultrasound measure. The strong
correlation between ATRA and ATLM
indicate consistency between the
indirect measures. The study cannot
recommend one measure over the
other. Further validation of these three
clinically applicable measures against
a true gold standard seems highly
needed.
154. Completeness and data validity in the Danish Achilles Tendon Database.
Allan Cramer, Maria Swennergren Hansen, Per Hölmich, Kristoffer Weisskirchner Barfod
Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery., Copenhagen University Hospital, Amager-Hvidovre.; Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C),Department of Physiotherapy and Occupational Therapy,, Copenhagen University Hospital, Amager-Hvidovre.; Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery., Copenhagen University Hospital, Amager-Hvidovre.; Sports Orthopedic Research Center - Copenhagen (SORC-C), Arthroscopic Center, Department of Orthopedic Surgery., Copenhagen University Hospital, Amager-Hvidovre.
Background: Acute Achilles tendon rupture (ATR) is a severe
injury that leads to functional deficits and sick leave.
No treatment consensus has yet been established.
Data from the Danish Achilles Tendon Database
(DADB) can help us monitor and optimize the
treatment.
Purpose / Aim of Study: To investigate the completeness and data validity in
DADB.
Materials and Methods: The study was performed as a registry study
comparing data in DADB with data collected from
the patient records. Data were collected from 3 of 11
hospitals registered in DADB. The study period was
the 1st of January to the 31st of December 2016.
Completeness was calculated as ‘patients correctly
registered in DADB’ divided by ‘patients eligible for
registration’. Validity was calculated as ‘patients with
correctly registered data’ divided by ‘patients
correctly registered in DADB’. A completeness of
80% was considered satisfactory and a parameter
was valid if there was agreement between DADB
and the patient record in 80% of the cases.
Findings / Results: The total completeness was 77% (155/201). For the
non-operated patients 81% (150/185) and the
operated patients 31% (5/16). The 7 investigated
parameters entered at registration of patients in
DADB all showed a validity of 83%-100%.
Conclusions: This study showed a satisfactory completeness of
data concerning the non-operated patients
registered in DADB and an unsatisfactory
completeness of data concerning operated patients.
All investigated parameters were valid. These
results suggest that data in DADB, for the non-
operated patients, rightfully can contribute to
research within the field. Due to a limited sample of
operated patients conclusions should be cautious.
The logistics concerning data collection among
operated patients need to be optimized.
155. Long term follow-up of patient reported outcomes and objective measures after acute Achilles tendon rupture: preferred surgical treatment vs. preferred functional rehabilitation
Laurine Nilsson, Inge Lunding Kjær, Andrius Kazlauskas, Jonas Bloch Thorlund, Marianne Christensen
Department of Sports Science and Clinical Biomechanics, University of Southern Denmark; Department of Orthopaedic Surgery, Aalborg University Hospital; Department of Orthopaedic Surgery, Aalborg University Hospital; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark; Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital
Background: The optimal treatment for acute Achilles tendon
rupture remains debated. Despite several studies
comparing treatment regimens, long-term follow-up
data is sparse.
Purpose / Aim of Study: We aimed to compare patient reported outcomes
and objective measures of function in acute Achilles
tendon rupture patients treated with a regimen
preferring either surgical treatment or functional
rehabilitation, measured 4 years after rupture.
Materials and Methods: 76 patients (22 women, 54 men) with a mean±SD
age of 54±13 at follow-up, who had followed a
regimen with surgical treatment or functional
rehabilitation as preferred treatment was included in
a 4 years follow-up. Patients were treated at Aalborg
University Hospital and recruited from the Danish
Achilles Tendon Database. At 4 years follow-up
patients completed the Achilles Tendon Total
Rupture Score (ATRS) and performed objective
physical measurements. Adverse events for the 4-
year period was noted. Students t-test and mixed
effect model was used for statistical data evaluation.
Findings / Results: We found no significant difference between the two
treatment regimens in ATRS-scores at 1, 2 and 4
years follow-up. Similarly, we found no difference in
change in ATRS-score between groups over time
(group x time interaction, p=0.85). Objective
measures at 4 years follow-up were no different
between regimens, calculated both in absolute and
relative values. Number of adverse events in both
groups was few and statistical comparison was not
performed.
Conclusions: 4 years after an acute Achilles tendon rupture no
differences were found in ATRS, objective measures
and incidence of adverse events between patients
following a regimen preferring surgical treatment
versus a regimen preferring functional rehabilitation.
156. Bone grafting and talo-calcaneal fusion for huge talar cyst with STAR ankle replacement
Johnny Froekjaer, Lasse Darling Andersen, Trine Torfing
Orthopedic Surgical Department, Odense University Hospital; Orthopedic Surgical Department, Odense University Hospital; Radiological Departmen, Odense University Hospital
Background: In Denmark the use of the STAR ankle
replacement is dominant. Long term
results show that cyst formation around
the ankle replacement is a problem,
potentially threatening the mechanical
stability, causing loosening of
components.
Purpose / Aim of Study: The aim of our study is to present our
results after treatment of big cysts under
the STAR talar component with
allogenous bone grafting and
talocalcaneal fusion.
Materials and Methods: Patients who earlier had a STAR ankle
replacement, complaining of pain
around the ankle were examined with
radiograhs, and cystic lesions under
the talar component were found.
Evaluation of cyst number and size
were done with a 3-D radiography - a
weight bearing scan. Included in the
study were patients, where cyst size
and location were threatening
mechanical stability of the component.
Treatment was surgery with removal of
all cyst content, allogenous bone
grafting through the talocalcaneal joint
and fusion with headless compression
screws. Histological examination was
made of cyst content.
At follow up results were evaluated
clinically and healing of bone grafting
and fusion of joint with 3-D scan.
Findings / Results: Twelve consecutive patients were
operated, four females and eight
males. Mean age at surgery was 59.9
years. Mean time from STAR to bone
grafting and fusion was 6.2 years.
Mean time from surgery to follow up
was 33 months. Histology showed non
specific inflammatory reaction.
Nine patients had uneventful healing,
with a good clinical result. Two patients
had a nonunion, components were
removed and a retrograde nail was
inserted. Both healed with an
acceptable clinical result. One patient
had a severe postoperative deep
infection and was treated with a bellow
knee amputation.
Conclusions: Treatment of talar cysts under STAR
ankle replacement with bone grafting and
talocalcaneal fusion gives a good result
157. Mid- and hindfoot reconstruction of Charcot foot with super construct device.
Johnny Froekjaer, Ellen Hamborg Petersen
University Center for Ulcer Healing, Plastic Surgical Department, Odense University Hospital; University Center for Ulcer Healing, Plastic Surgical Department, Odense University Hospital
Background: Charcot foot reconstruction has been
disappointing due to a high complication
rate. Recently super construct implants
have been available, including
intramedullary screws and reconstruction
plates.
Surgical concept is complete fusion of
medial and/or lateral column, to increase
stability.
Purpose / Aim of Study: The aim of this study is to present the
results of 8 charcot foot patients treated
with this concept.
Materials and Methods: 8 patients with severe deformity due to
charcot foot were operated from July
2017 to May 2018. All patients had a
threatening pre ulcer situation or
instability. Mean age was 59.5 years, 5
males and 3 females with a mean
weight of 127 kg, mean BMI 38,9.
Peripheral vascular supply was good in
all cases. Patients were immobilized in
a plaster cast mean 19.3 weeks, until
acute inflammation had decreased and
surgery was safe.
Standard surgical technique with
preparation of all joints was performed,
in case of talocalcaneal joint instability
this joint was also fused. Fusion of
medial column was mandatory, lateral
column if required.
A tourniquet was used in the first 4
cases, but was abandoned in the last
cases.
Findings / Results: Mean surgical time was 223 min. Medial
fusion was performed in all cases, 2
cases as an isolated procedure. 4 cases
had both medial and lateral column
fusion. 2 cases had talocalcaneal and
medial column fusion.
Mean follow up time is 28.4 weeks.
2 patients in the tourniquet group had
skin necrosis, one requiring removal of
plate. 1 patient without tourniquet had
skin necrosis.
2 patients are still in a plaster cast, 6 had
healing of incision, had bone fusion and
are ambulated in orthopedic shoes.
We had no infections or amputations.
Conclusions: Results after charcot foot reconstruction
with super construct device seems
promissing. There is a learning curve and
tourniquet should be abandoned.
158. Correction of 1st MTP-joint arthrodesis with a bow-shaped osteotomy
Marianne Toft Vestermark, Andrius Kazlauskas
Department of Orthopaedic Surgery, Central Jutland Regional Hospital, Viborg; Department of Orthopaedic Surgery, Aalborg University Hospital
Background: Arthrodesis of the 1st MTP-joint is most
commonly performed on the basis of sever
Hallux Ridigus The MTP-joint is
positioned in 10-20 degrees dorsiflexion
and 10 degrees valgus in order ease
ambulation. Overcorrection into hyper
dorsiflexion is a known complication but
correction is not well described in the
literature.
Purpose / Aim of Study: Present a technique for correction of
hyper dorsiflexed MTP-1 arthrodesis.
Materials and Methods: A right MTP-1 joint was fused due to
sever hallux ridigus. The primary
surgery was uneventful until transferred
into normal shoes at 6 weeks. Complains
were of impingement pain with the
toe-box of the shoes dorsomedially over
the Interphalangeal joint of the first
toe and plantar under the caput first
metatarsus. In standing position, the
MTP-1 joint was both clinically and
radiographically in hyper dorsiflexion
and with full plantarflexion over the IP
joint the toe had no contact with the
ground.
Conservative treatment with costume-made
orthosis and use of shoes with spacious
toe-box was unsatisfactory.
Operative correction was performed with
a V-shaped osteotomy tilted proximally
from dorsum to the plantar of the first
toe-ray like the front bow of a ship.
When the toe was slided downward the tip
was further moved plantar. Shortening of
the toe was hereby minimized. The
osteotomy was fixated with two crossing
screws.
Findings / Results: The surgery as well as the
post-operative treatment was uneventful.
The patient was greatly relieved by the
correction and was 6 weeks
post-operatively transferred to ordinary
shoes.
The bow-shaped osteotomy for correction
reduced the dorsiflexion of the toe from
46 degrees to 33 degrees.
Conclusions: A bow-shaped osteotomy was successful in
correction of primary hyper dorsiflexed
arthrodesis of the 1st MTP-joint.