Session 3: Sports Orthopaedics / Shoulder

Onsdag den 24. oktober
11:00 – 12:00
Lokale: Helsinki/Oslo
Chairmen: Kristoffer Barfod og Klaus Bak

19. Endoscopic fasciotomy is a good and safe primary treatment for plantar fasciitis: A randomized controlled trial.
Finn Johannsen, Lars Konradsen, Robert Herzog, Michael Krogsgaard
Institute of sportsmedicine Copenhagen, Ortopæd kirurgisk afdeling, Bispebjerg Hospital; idrætskirurgisk enhed, ortopæd kirurgisk afdeling, Bispebjerg Hospital; fysioterapien, Bispebjerg Hospital; idrætskirurgisk enhed, Ortopæd kirurgisk afdeling, Bispebjerg Hospital

Background: Plantar fasciitis (PF) is a frequently diagnosed condition. Lifetime incidence 10%. Operation is normally only considered in PF that is refractory for non- surgical treatment.
Purpose / Aim of Study: Is operation useful as primary treatment in PF.
Materials and Methods: 30 consecutive patients with PF for more than 3 months were randomized to 1) conservative treatment with training and glucocorticoid injection; 2) endoscopic 2-incision technique of partial fasciotomy and heel spur removal. Patients were evaluated at entry, 3,6,12,24 months with the Foot Function Index (FFI, range 0-230) and pain during activity on a 100 mm VAS score (VAS-activity). FFI at 6 and 12 months were defined a-priory as primary endpoints.
Findings / Results: We found no intergroup difference at baseline, 3 and 6 months. Endoscopic operation were significantly better for the primary endpoints at 12 months in FFI (p=0.033) compared to non- surgical treatment, and at 24 months there were still a strong tendency in favor of operation in FFI (p=0.06). VAS-activity were without intergroup differences at 12 month, but at 24 months we found a significant intergroup difference (p=0.001) in favor of operation. Both groups improved significantly over time. From entry to 3 months, 6 months, 12 months and 24 months mean FFI in the surgery group was 107, 67, 25, 16 and 4 and mean VAS pain during function was 50, 31, 11, 10 and 1. For the non-surgery group mean FFI changed from 118 to 48, 32, 33 and 9, and mean VAS pain during function changed from 67 to 44, 24, 10 and 13. No severe complications were observed.
Conclusions: We found a beneficial effect in the long term (1 and 2 years) of operation for plantar fasciitis compared to best conservative practice in a randomized controlled trial. Endoscopic fasciotomy is a good and safe alternative as primary treatment for plantar fasciitis.

20. Sterno-clavicular arthroscopy – technique and experience with 57 procedures.
Michael Rindom Krogsgaard, Martin Rathcke
Section for sportstraumatology M51, Bispebjerg and Frederiksberg Hospital; Section for sportstraumatology M51, Bispebjerg and Frederiksberg Hospital

Background: There are only few, small treatment series on arthroscopic treatment of the sternoclavicular joint (SCJ) in literature. This procedure may provide better visualization of the joint and have lower morbidity than open procedures.
Purpose / Aim of Study: To report the technique of SCJ- arthroscopy and experience from a prospective, consecutive series of patients.
Materials and Methods: We established an operative technique on cadavers, and treated 57 patients with unilateral painful conditions by SCJ arthroscopy. DASH and Oxford Shoulder Score (OSS) were filled in before the operation and at 1, 2 and 5 years. Findings and complications were recorded.
Findings / Results: In 10 cases it was not possible to insert the scope: 2 joints were anchylotic, in 1 the subcutaneous fat was extensive, and in 7 osteophytes blocked. The majority had discus resection and cartilage debridement/medial clavicle end resection. In 2 the disc was sutured and in 2 loose bodies were removed. There were no infections or bleedings and no case of penetration of the posterior capsule. In one case instability occurred after resection of osteophytes and in another an interposition plasty with a gracilis tendon was performed for persisting pain despite resection of the medial clavicle end. DASH was median 53 (range 30-94) preoperatively, 38.5 (25-108) (p<0.05) at 1 year and 37 (24-102) at 2 years. Worst pain item from OSS was mean 2,6 preoperatively, 1,9 at 1 year (p<0.05) and 1,7 at 2 years. Usual pain- item was 2,15 preoperatively, 1,4 at 1 year (p < 0.05) and 1,1 at 2 years. Pain at night was 2,4 preoperatively, 1,3 at 1 year (p<0,05) and 1,4 at 2 years.
Conclusions: SCJ arthroscopy is safe and clinical results are comparable to or better than after similar open procedures. Patients should be prepared for conversion to open surgery, if osteophytes block the way.

21. Restoration of knee laxity in combined ACL plus ALL deficiency -Comparison of Intra-articular Hamstrings Tendons Graft versus the Modified intra- and extra-articular Iliotibial Tract Graft: A Cadaveric Study
Salamah Belal Eljaja, Lars Konradsen, Volkert Siersma, Kiron Athwal, Andre Arthur Amis, Michael Rindom Krogsgaard
Section of Sports Traumatology M51, Bispebjerg Hospital; Section of Sports Traumatology M51, Bispebjerg Hospital; Dep. of Public Health, University of Copenhagen; Dep. of Biomechanical Engineering, Imperial College London; Dep. of Biomechanical Engineering, Imperial College London; Section of Sports Traumatology M51, Bispebjerg Hospital

Background: The strength of a double stranded iliotibial tract graft is comparable to the strength of the natural anterior cruciate ligament (ACL) and with its attachment to Gerdy’s tubercle it might restore knee stability better in the ACL + anterolateral ligament (ALL) insufficient knee, compared to standard intraarticular techniques for ACL reconstruction (ACLr).
Purpose / Aim of Study: The aim of this study was to measure and compare knee kinematics before and after ACL resection, ALL resection and ACL reconstruction using hamstring graft (HG) and modified iliotibial tract (MIT) graft, respectively.
Materials and Methods: Fourteen cadaveric knees were tested in a 6 degree of freedom kinematics rig. An optical tracking system recorded kinematics of the knee from 0° to 80° of flexion applying no load, internal rotation (IR), external rotation, valgus rotation, varus rotation (VRR), simulated pivot shift (SPS), anterior translation (AT) and posterior translation loads. Test in following states: Intact, after ACL resection, after ALL resection, after HG-ACLr and MIT-ACLr. Grafts were fixed at 20° of flexion. Results were compared to intact.
Findings / Results: P-value<0,05 ACL resection increased AT in all degrees of flexion, peak at 20°, mean diff. 6.6±2.25 mm. ACLr with HG- ACL and MIT-ACL restored AT. Resection of the ALL increased IR in the fully extended knee, mean diff. 2.4±2.1°. MIT-ACLr, reduced IR and SPS compared to HG-ACLr and the intact knee in deep flexion angles (60-80°), peak at 80°, mean diff. -6.2±2.1° and -5.4±2.2° for IR and SPS, respectively. The MIT- ACLr caused less VRR at 80° flexion, mean diff. -2.7±1.9°.
Conclusions: MIT-ACLr restored AT equally to the HG-ACLr. The MIT-ACLr had a restraining influence on IR and SPS in deep flexion. This may be protective against re- rupture, though it could have an overconstraining effect on knee.

22. Discus preserving reconstruction of recurrent anterior sterno-clavicular instability in young persons: a 1-5 years follow-up.
Martin Rathcke, Rikke Høffner, Michael Rindom Krogsgaard
Section for sportstraumatology M51, Bispebjerg and Frederiksberg Hospital; Department of physiotherapy, Bispebjerg and Frederiksberg Hospital; Section for sportstraumatology M51, Bispebjerg and Frederiksberg Hospital

Background: Non-traumatic recurrent anterior instability of the sternoclavicular joint (SCJ) is a disabling condition in young persons. If physiotherapy fails, surgical treatment is indicated. Traditionally the discus is resected, but in young persons it should be saved. We introduce a stabilizing procedure that is preserving the discus. It uses a gracilis autograft to form a triangular reconstruction of the anterior SCJ capsule, anchoring the graft to manubrium and the medial clavicle.
Purpose / Aim of Study: To present the 1-5 year-result of this discus preserving SCJ reconstruction for recurrent anterior dislocation in a prospective cohort.
Materials and Methods: 30 SCJs (16 right /14 Left) in 25 patients (5 had bilateral instability) were operated for recurrent dislocation of the SCJ during the period 2010-17. Two patients had a re-operation due to recurrence of the SCJ instability. Allografts were used in two patients, one primary and one re-operation. All patients filled in the DASH questionnaire before the operation and at 1, 2 and 5-year follow-up. Stability, pain and satisfaction were also registered.
Findings / Results: Mean age at operation was 19 years (13-30). In 5 patients, the procedure was bilateral. At 1-year follow-up there was 4 re- instabilities, and two of these were re- operated. 26 SCJ = 87 % were considered stable. One patient had suture of a torn disc. Two patients complained of donor pain, and 3 patients had keloid formation in their scar. DASH was significantly better at follow-up (p<0.05).
Conclusions: The 1 – 5 year results of this procedure were satisfactory. As it preserves the discus- and joint, we suggest it is used in young patients with SCJ instability who needs surgery.

23. Revision hip arthroscopy, indications and outcomes: a follow-up study of 269 femoroacetabular impingement (FAI) patients. Results from the Danish Hip Arthroscopy Registry (DHAR).
Andreas Chatterton, Torsten Grønbech Nielsen, Bent Lund, Ole Gade Sørensen, Bjarne Mygind-Klavsen, Martin Lind
Department of Sports Traumatology, Aarhus University Hospital; Department of Sports Traumatology, Aarhus University Hospital; Department of Orthopaedic Surgery, The Regional Hospital in Horsens; Department of Sports Traumatology, Aarhus University Hospital; Department of Sports Traumatology, Aarhus University Hospital; Department of Sports Traumatology, Aarhus University Hospital

Background: Hip arthroscopy is the standard surgical intervention for intraarticular hip pathologies such as cam, pincer and labral tears. However, limited knowledge exists concerning the causes for failure, and outcomes after revision hip arthroscopy.
Purpose / Aim of Study: The purpose of this study is to evaluate the causes of failure after primary hip arthroscopy and clinical outcomes after revision hip arthroscopy. Moreover, the study aims to compare primary and revision hip arthroscopy outcome scores.
Materials and Methods: 269 FAI patients (90 males and 179 females) were included from DHAR, with failed primary hip arthroscopic procedure and performed revision procedure. The mean age was 39.3 (SD 10.1). Patient related outcome measures consisting of Copenhagen Hip and Groin Outcome Score (HAGOS), quality of life (EQ-5D), Hip Sports Activity Scale (HSAS), International Hip Outcome Score (IHOT12) and Numeric Rating Scale (NRS) pain scores were assessed prior to surgery, 1 and 2 years post-operatively. Clinical outcomes were compared with a primary hip arthroscopic patient cohort.
Findings / Results: Females had a median relative risk of undergoing revision hip arthroscopy of 1.71 compared to males. At 2-year follow-up after revision hip arthroscopy we observed significant improvements in all outcome scores. Primary hip arthroscopic outcomes in FAI patients were significantly better than after FAI revision hip arthroscopy, in all scores.
Conclusions: Females have an increased risk of revision after FAI arthroscopic treatment. Revision hip arthroscopy in FAI patients improves subjective outcomes significantly, although they are poorer than after primary hip arthroscopy. The clinical relevance of this study is that revision hip arthroscopy is a valuable treatment option in cases of failed primary hip arthroscopy in FAI patients.

24. Combined Bone Marrow Aspirate and Platelet-rich Plasma for Cartilage Repair – Results at Two-Year Follow-Up
Kris Tvilum Chadwick Hede, Bjørn Borsøe Christensen, Jonas Jensen, Casper Bindzus Foldager, Martin Carøe Lind
Orthopedic Research Laboratory, Aarhus University Hospital; Orthopedic Research Laboratory, Aarhus University Hospital; Department of Radiology, Aarhus University Hospital; Orthopedic Research Laboratory, Aarhus University Hospital; Sports Trauma Clinic, Aarhus University Hospital

Background: Cell-based cartilage repair treatments are limited due to high costs of cell expansion prior to implantation. The use of autologous bone marrow aspirate concentrate (BMAC) has been proposed as an alternative one- step strategy. Platelet-rich plasma (PRP) is an increasingly popular endogenous source of concentrated growth factors.
Purpose / Aim of Study: To evaluate the clinical use of combined BMAC and PRP on a collagen I/III scaffold for treating cartilage lesions in the knee.
Materials and Methods: Ten patients (Mean age: 29.4 years, range 18-36) suffering from large full-thickness cartilage lesions on patella (n=7) or the femoral condyles (n=3) were treated with BMAC and PRP from January 2015 to December 2016. Bone marrow was aspirated from the iliac crest and was prepared using centrifugation to yield BMAC. PRP was prepared using whole blood. BMAC and PRP was then seeded onto a collagen I/III scaffold and sutured into the debrided defect. Patients were evaluated by clinical outcome scores (IKDC, KOOS and VAS) pre- operatively, after three months, one and two years and through MRI pre-operatively and after one year, evaluated using MOCART score.
Findings / Results: At one-year follow-up a significant improvement was found in IKDC (35.5 to 58.4, p = 0.003), VAS activity (7.3 to 4.9, p = 0.006), KOOS symptoms (60.5 to 77.5, p = 0.026) and KOOS QOL (23.2 to 41.9, p = 0.026). MOCART score improved from 19.5 to 36.5 (p = 0.015). At two years follow-up (n=8) improvements were seen in all scores, but none were statistically significant.
Conclusions: Treatment of cartilage injuries using combined BMAC and PRP resulted in improvements in subjective outcome and MOCART scores one year postoperative, which were non-significant after two years.

25. Quadriceps tendon (QT) graft has higher revision rates than hamstring and patellatendon grafts for anterior cruciate ligament (ACL) reconstruction. Results from the Danish Knee Ligament Reconstruction (DKRR)
Martin Lind, Marc Strauss, Torsten Nielsen
Orthopedics, Aarhus University Hospital; Orthopedics, Ullevaal Hospital, Oslo, Norway; Orthopedics, Aarhus University

Background: Quadriceps tendon (QT) has recently gained increase interest as ACL reconstruction graft due to introduction of minimal invasive harvesting techniques and low donor site morbidity. There is a lack of data on failures and revision rates from large sized cohorts.
Purpose / Aim of Study: The aim of this study is to present objective knee stability, subjective outcome in patients after ACL reconstruction with QT graft and compared these with hamstring (HS) and patellatendon (PT) grafts based on results from DKRR. We hypothesized similar stability, subjective outcome and revision rates as hamstring and patella tendon grafts.
Materials and Methods: Respectively 425, 2639 and 18709 of QT, PT and HS tendon ACL reconstructions were registered in the DKRR between 2005 and 2016. Objective outcomes of sagittal knee laxity, positive pivot shift, patient- reported outcome (KOOS) at one-year follow-up and revision rates at 2 years was used to compare the outcome of the 3 graft cohorts.
Findings / Results: QT graft usage was associated with more knee laxity than HS and PT grafts of 1,7, 1.6 and 1,5 mm respectively. Also a higher rate of positive pivot shift (21 %) was found for QT grafts versus PT (18 %) and HS tendon (17 %). KOOS outcome demonstrated improvement for all graft types from pre- to postoperative with no difference between graft types. Revision rates after 2 years were 4,9, 1,6 and 2,3 % for QT, PT and HS tendon ACL reconstructions
Conclusions: QT graft for ACL reconstruction demonstrated excellent improvements in knee laxity and subjective outcome similar to PT and HS tendon grafts. However QT graft was associated with a concerning high rate of revision within two years and more knee laxity. We do not conclude similar outcome for QT, PT and HS tendon ACL reconstructions as hypothesized.