Session 4: Technical Notes / Cases
Onsdag den 24. oktober
17:30-18:30
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.
27. CUSTOM MADE POLYETHYLENE LINER TO CORRECT TIBIAL COMPONENT MALALIGNMENT IN A CASE WITH PROXIMAL TIBIAL DEFORMITY.
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.