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.