Session 4: Technical Notes / Cases

Onsdag den 24. oktober
Lokale: Reykjavik
Chairmen: Martin Gotliebsen og Kirill Gromov

26A. Cost-utility analysis of Patellofemoral Arthroplasty versus Total Knee Arthroplasty for Isolated Patellofemoral Osteoarthritis
Charlotte Fredborg, Anders Odgaard, Jan Sørensen
Region Hovedstaden, Region Hovedstaden; Ortopædkirurgisk afd., Gentofte Hospital; Royal College of Surgeons in Ireland (RCSI), RCSI Research Centre Dublin

Background: It has become modern practice to consider healthcare interventions as attractive if they fall below a specified threshold value per extra quality-adjusted life year (QALY). In Europe, the threshold is approx. 30,000 €. In Denmark, it has been suggested that the threshold value is at least 160.000 DKK per extra QALY. This study takes this modern perspective and compare the cost-effectiveness of two knee implants
Purpose / Aim of Study: Using CUA to assess whether patellofemoral arthroplasty (PFA) is more cost-effective than total knee arthroplasty (TKA) in patients with isolated PF-OA.
Materials and Methods: The CUA used a 12-month hospital perspective and considered data from a RCT with 100 patients randomised to either PFA or TKA. Patients completed OKS, SF-36 and EQ-5D at baseline, and several times postoperatively. The utility measure estimated was QALYs. An activity-based costing model applied data from clinical records, registers and patient-reported resource use. Unit costs were obtained from hospitals’ financial departments. The Incremental Cost Effectiveness Ratio (ICER) were calculated, and the statistical uncertainty presented in acceptability curves.
Findings / Results: The incremental utility gain was positive and the incremental costs negative for the PFA-group in comparison with TKA. The cost difference was not statistical significant in the base-case with implant cost assumed at similar cost. At a threshold value of 15,000€ per QALY the PFA appeared to be cost-effective with a high probability.
Conclusions: Knee arthroplasty is a cost-effective treatment. The 12-month outcomes appeared to be better and healthcare costs lower in the PFA-group. PFA may be the preferred arthroplasty compared to TKA for isolated PF-OA from a health economic perspective. Longer-term follow-up of implant survival and society-based CUAs are advised.

26B. Os epilunatum as a rare cause of wrist pain. A case report
Charlotte Hartig-Andreasen, Bo Munk
Orthopedic Surgery, Aarhus University Hospital; Orthopedic Surgery, Aarhus University Hospital

Background: Atraumatic wrist pain may be due to accessory carpal ossicles. The incidence of ossicles in the wrist is 1.6%. An epilunatum is an extreme rare ossicle located dorsal to the scaphoid, lunate and the capitate. Only one clinical case with an epilunatum is described in the literature.
Purpose / Aim of Study: To describe a atypical cause of chronic wrist pain, and result of surgery.
Materials and Methods: Case presentation: A 28-year-old male IT- worker with right-handed wrist pain through 6 years. At that time he was employed as a contractor, but due to increasing wrist pain and decreased extension of the wrist he changed to a job with less manual work. No history of trauma. Clinical exam of the hand showed active extension close to 0° and flexion to 30°-40°. No symptoms from the opposite hand.
Findings / Results: Lateral wrist radiographs showed an ossicle dorsal to the lunate. Magnetic resonance imaging showed an os epilunatum with a fibrous connection to the lunate. The scapholunate (SL) and lunotriquetral (LT) ligament was intact. At surgery a dorsal approach was used. The epilunatum clearly collided with the dorsal rim of radius preventing extension of the wrist. The epilunatum was enucleated without damaging the SL and the LT ligament. Postoperatively extension increased to 60 degrees, and he achieved full flexion. For maintaining the achieved range of motion the patient was referred to hand therapy. At 3 months follow-up, the patient was pain free. Active/passive extension was 50°/60° and flexion 45°/75°.
Conclusions: Discussion: Chronic wrist pain may be caused be accessory ossicles. The epilunate is close related to the SL ligament, and surgery is not without risk of compromising the stability of the hand. In our case enucleation of the epilunatum resolves the pain and improves range of motion without causing instability of the hand.

26C. A case of early diagnostics and treatment of complex regional pain syndrome (CRPS)
Charlotte Hartig-Andreasen, Jytte F. Møller, Claus Möger
Orthopedic Surgery, Aarhus University Hospital; Anesthesiology, Aarhus University Hospital; Orthopedic Surgery, Aarhus University Hospital

Background: CRPS after wrist surgery is a well-known risk. It is a neurological condition requiring early diagnosis, multidisciplinary treatment including intensive hand therapy to avoid a chronic condition.
Purpose / Aim of Study: To present a CRPS case treated with ketamine and methadone.
Materials and Methods: 27-year-old man underwent wrist fusion with a dorsal plate due to posttraumatic osteoarthritis secondarily to carpal instability.
Findings / Results: Postoperatively pain was controlled with regional block. After two days the patient developed severe pain. Fentanyl and amitriptyline treatment was initiated for neuropathic pain. At day 6 the pain was intractable, and CRPS suspected. Treatment with prednisolone, calcium, alendronate and pantoprazole was started. The following two days CRPS became fulminant. Infection was excluded. Despite medical treatment pain continued to be intractable making intensive hand therapy impossible. At day 8 ketamine infusion in sub anesthetic doses was given with immediate effect and oral methadone started. Pain intensity reduced, discoloration diminished and hand therapy resumed. After 16 days reduction in ketamine was initiated. Twenty-four days after surgery, ketamine infusion was discontinued; the patient was pain free on methadone and discharged.
Conclusions: Correct diagnosis and multidisciplinary treatment including anesthesiologist, hand surgeons and intensive hand therapy was initiated immediately resulting in complete remission 24 days after surgery. Ketamine infusion is not without risk, and whether ketamine should be used in acute/chronic CRPS, or in anesthetic/sub anesthetic doses remains unknown. Only few small studies exist and are inconclusive. In this case infusion of ketamine in sub anesthetic doses combined with methadone was efficacious in controlling the pain, making intensive hand therapy possible.

Kappel Andreas, Blom Claes Sjørslev, El-Galaly Anders
Aalborg, Aalborg University Hospital; Aalborg, Aalborg University Hospital; Aalborg, Aalborg University Hospital

Background: TKA revision can be challenging in cases with bony deformity that do not allow the use of standard revision implants.
Purpose / Aim of Study: To present the use of an asymmetrical custom made liner in the revision of a case with isolated tibial malpositioning and tibial deformity.
Materials and Methods: Case story: 54-year-old woman with complaints of instability and malalignment from her right total knee arthroplasty (TKA). Previous surgeries included proximal tibial osteotomy to correct recurvatum following a midshaft tibial fracture, primary TKA and a femoral revision. Clinical examination revealed excessive valgus, unaffected range of motion (ROM), moderate soft-tissue laxity and a well-aligned foot. Radiographs, CT and EOS showed coronal malpositioning of the tibial component and sagittal tibial deformity, no signs of component loosening or malrotation, valgus angle of 9 degrees. Revision of the malpositioned tibial component was planned, but templating revealed that none of the available standard implants would fit the sagittal bony deformity. A custom-made polyethylene was designed with a medial build up to correct varus and a slight posterior build up to correct excessive slope of the tibial component. Revision surgery was uneventful, following moderate medial release the liner was inserted and both alignment and stability was found satisfying.
Findings / Results: At short time follow up the patient is relived from her complaints, both ROM, alignment and stability is clinically satisfying. Postoperative EOS- scan shows 1 degree of valgus.
Conclusions: The use of custom-made liner might be an alternative to tibial component revision in cases with isolated tibial mal-positioning and well fixed component. Longevity can be a concern due to asymmetric stresses on both tibial bony fixation and locking mechanism.

28. Debridement of open fractures in children. Vital or not, that is the question.
Juozas Petruskevicius, Jan Duedal Rölfing
Traumatolgy and Reconstructive Surgery Unit, Department of Orthopaedics, Aarhus University Hospital; Traumatolgy and Reconstructive Surgery Unit, Department of Orthopaedics, Aarhus University Hospital

Background: Sound evidence exists regarding the management of open fractures in adults. In contrast, the evidence is scarce in children. The remarkable biology of the growing body makes children more resilient and tissue that appears almost dead may be salvaged. However, a wrong decision resulting in incomplete debridement may deteriorate the clinical outcome.
Purpose / Aim of Study: To highlight the difficulties in decision-making when debriding open fractures in children and adolescents
Materials and Methods: A 14-year-old boy’s legs were crushed between the bumper of a car and a concrete block. Substantial degloving injuries with muscular and bony damage (Gustilo 3B) were present bilaterally with a severely comminuted tibia shaft fracture on the left leg and a 3-part tibia fracture on the right leg. Sensation was present, and pulses were weak.
Findings / Results: Initial treatment consisted of antibiotics, wash out, primary debridement, external fixation, photo- documentation, CT and planning. Secondary debridement took place in the presence of experts in plastic surgery and traumatology 18 hours after injury. On the worse, left side, 9 cm bony resection and bone transportation was performed via ring fixation. On the right side, an intermediate, 8 cm periosteal-stripped fragment was decided to be retained. In adults, resection would have been mandatory. After definitive treatment with soft tissue coverage and ring fixation, this bony fragment was completely incorporate. Both legs healed without infection and with an excellent functional outcome.
Conclusions: Debridement of severe open fractures is challenging. The grey area of tissue that can be salvaged is wider in children and adolescents than in adults. Expertise in advanced traumatology and plastic surgery are crucial to perform secondary debridement and to manage severe open fractures routinely.

29. Surgical Fenestration and rehabilitation of a non-union, after sport traumatic tuber Ischiadicum Avulsion fracture – Case report
Jens Erik Jorgensen
, Physiotherapy Clinic, Sofiendalsvej 92A. 9200. Aalborg SV. Denmark

Background: Ischial tuberosity fractures and complications may be an under recognized diagnosis in adolescent athletes. Operative interventions differ and may include anchor re-fixations, resections and osteostimulating drilling and partial hamstring releases.
Purpose / Aim of Study: This case report illustrates a novel and less invasive management of a non- union following a proximal ischial tuberosity avulsion. This approach has to our knowledge not previously been described.
Materials and Methods: The patient, a 14 years old female athlete, was complaining of sharp pain in the right side of the groin region, after an acute injury during a handball game. The pain was concentrated at the insertion of the adductor muscle group to the superior pubic ramus and the pubic symphysis. She was referred to our orthopaedic sports clinic after 6 months of unsuccessful conservative treatment. An MRI scan showed an ischial tuberosity non-union with a displacement less than 10mm. Nine months after injury a surgical procedure was performed with the patient under general anaesthesia. An ultrasound guided fenestration of the pseudoarthrosis of the ischial tuberosity with a 1.6 mm Kirshner wire was performed. The enthesis was fenestrated 10 times, using a 1.2 mm syringe. Finally, a 5ml local anaesthetic was injected in the area.
Findings / Results: 17 months after the trauma and 11 months postoperatively the patient had a full return to normal day activities including pain free squats and lunges. Radiologically the non-union was healed.
Conclusions: This novel and less invasive surgical procedure may therefore be seen as a possible treatment option to non-union of the ischial tuberosity with minimal displacement.

30. The rare presentation of a distal forearm fracture in conjunction with a Bado type III Monteggia fracture
Nicolai Kjældgaard Kristensen, Mathias Bünger, Jan Duedal Rölfing
Department of Orthopaedics, Aarhus University Hospital; Department of Orthopaedics, Aarhus University Hospital; Department of Orthopaedics, Aarhus University Hospital

Background: virtually unknown for many physicians. In contrast, distal humerus fractures commonly occur in conjunction with ipsilateral fractures and dislocations in children. Overlooked and hence untreated Monteggia fractures can result in devastating functional outcome.
Purpose / Aim of Study: To raise awareness of this injury entity and to highlight the need of examining the entire patient in order to identify associated injuries
Materials and Methods: A 4-year-old girl fell from a swing and landed on an outstretched arm. She sustained a distal forearm fracture with preserved sensation and capillary refill. Meticulous examination also revealed direct and indirect tenderness around the ipsilateral elbow. Radiologic examination showed a dorsally displaced distal forearm fracture in combination an olecranon fracture including minor intraarticular step-off. The overlooked laterally-luxated radial head (Bado type III Monteggia fracture) was diagnosed the following day.
Findings / Results: The patient was scheduled for closed reduction and internal fixation with Kirschner wires. The Monteggia fracture was reduced and the olecranon fracture fixated with a single intramedullary Kirschner wire. Adequate reposition of the radial head and joint congruity were confirmed with an intraoperative arthogram. Finally, the distal forearm fracture was reduced and a long arm cast was applied from the upper arm to the metacarpal heads. Follow-up took place in the outpatient clinic after 1 week, 4 weeks and 3 months and the radiographic and functional outcome was recorded.
Conclusions: This case underlines the need for proper physical and appropriate radiologic examination of children with forearm fractures in order to identify and treat all injuries.