Foot and Ankle
Allan Cramer, Kristoffer Weisskirchner Barfod, Per Hölmich, Kaare Christensen, Dorthe Almind Pedersen
Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Hvidovre Hospital; Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Hvidovre Hospital; Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Hvidovre Hospital; Department of Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, Odense; Department of Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, Odense
Background: The etiology and pathogenesis of acute Achilles tendon rupture (ATR) are complex and not fully understood. Some studies have shown possible associations between specific genes and ATR. No twin studies have yet investigated the genetic component of ATR.
Purpose / Aim of Study: To identify a possible genetic component in the risk of ATR.
Materials and Methods: The study was performed as a registry study using the Danish Twin Registry and the Danish National Patient Registry. Twins registered with the diagnosis codes DS86.0 and DS86.0A were retrieved and the probandwise concordance for monozygotic (MZ, ∼100% identical genetics) and same-sex dizygotic (ssDZ, ∼50% identical genetics) were calculated. If the probandwise concordance rate in the MZ twins was larger compared to the ssDZ twins, the results suggest a genetic component of the etiology.
Findings / Results: From 1994 to 2014, 577 twin pairs were registered in the Danish Twin Registry with at least one of the twins having had an ATR. Of those, 122 were MZ (5 concordant pairs, 117 discordant pairs) with a probandwise concordance rate of 0.079 (CI 95% 0.027;0.170) and 230 were ssMZ (5 concordant pairs and 225 discordant pairs) with a probandwise concordance rate of 0.043 (CI 95% 0.014;0.095). No statistically significant difference between the groups was found (p-value 0.31).
Conclusions: If one twin of a pair have had an ATR, this study found a risk of ATR for the second twin of 8% for a MZ twin and 4% for a ssDZ. The larger probandwise concordance rate for MZ twins compared to ssDZ speaks for a genetic component in the etiology, however the finding was not statistically significant and no definite conclusions can be made.
Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Hvidovre Hospital; Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Hvidovre Hospital; Sports Orthopedic Research Center – Copenhagen (SORC-C), Department of Orthopedic Surgery, Hvidovre Hospital; Department of Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, Odense; Department of Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, Odense
Background: The etiology and pathogenesis of acute Achilles tendon rupture (ATR) are complex and not fully understood. Some studies have shown possible associations between specific genes and ATR. No twin studies have yet investigated the genetic component of ATR.
Purpose / Aim of Study: To identify a possible genetic component in the risk of ATR.
Materials and Methods: The study was performed as a registry study using the Danish Twin Registry and the Danish National Patient Registry. Twins registered with the diagnosis codes DS86.0 and DS86.0A were retrieved and the probandwise concordance for monozygotic (MZ, ∼100% identical genetics) and same-sex dizygotic (ssDZ, ∼50% identical genetics) were calculated. If the probandwise concordance rate in the MZ twins was larger compared to the ssDZ twins, the results suggest a genetic component of the etiology.
Findings / Results: From 1994 to 2014, 577 twin pairs were registered in the Danish Twin Registry with at least one of the twins having had an ATR. Of those, 122 were MZ (5 concordant pairs, 117 discordant pairs) with a probandwise concordance rate of 0.079 (CI 95% 0.027;0.170) and 230 were ssMZ (5 concordant pairs and 225 discordant pairs) with a probandwise concordance rate of 0.043 (CI 95% 0.014;0.095). No statistically significant difference between the groups was found (p-value 0.31).
Conclusions: If one twin of a pair have had an ATR, this study found a risk of ATR for the second twin of 8% for a MZ twin and 4% for a ssDZ. The larger probandwise concordance rate for MZ twins compared to ssDZ speaks for a genetic component in the etiology, however the finding was not statistically significant and no definite conclusions can be made.
Ebrahim Rahdi, Allan Cramer, Kristoffer Barfod
Department of orthopedic surgery, Sport Orthopedic Research Center – Copenhagen (SORC-C) , Hvidovre Hospital; Department of orthopedic surgery, Sport Orthopedic Research Center – Copenhagen (SORC-C) , Hvidovre Hospital; Department of orthopedic surgery, Sport Orthopedic Research Center – Copenhagen (SORC-C) , Hvidovre Hospital
Background: For decades, the choice of operative or non- operative treatment of acute Achilles tendon rupture has been debated. Few studies present data on the difference in functional outcomes.
Purpose / Aim of Study: To compare functional outcomes in operative and non-operative treatment of acute Achilles tendon rupture.
Materials and Methods: The study was performed as a register study from the Danish Achilles tendon Database. The primary outcome was the Achilles Tendon Resting Angle (ATRA) 12 months post-injury. The secondary outcomes, assessed 12 months post-injury, were heel-rise height, Achilles tendon Total Rupture Score (ATRS), return to pre-injury work and sport, as well as satisfaction with the treatment and the result. Comparison between operative and non-operative treatment was performed using multiple linear and logistic regression analysis, controlling for sex, age, diabetes, rheumatism, hypertension, treatment with corticosteroids, hospital of treatment and age of the rupture.
Findings / Results: 364 patients were included in the study population from August 2016 to January 2019. ATRA showed a statistically significant difference of 1.67 degrees (CI: -2.83; -0.52; P = 0.0047) in favor of operative treatment. Also, operatively treated patients had statistically significantly better odds (odds ratio 2.2 (CI: 1.07; 4.72; P = 0.038)) of returning to the same type of sports. There was no statistically significant difference in heel-rise height, ATRS, return to pre-injury work or satisfaction with the result and treatment.
Conclusions: This study found a statistically significant difference in the primary outcome (ATRA) in favor of operative treatment compared to the non-operative. This difference is not considered clinically relevant.
Department of orthopedic surgery, Sport Orthopedic Research Center – Copenhagen (SORC-C) , Hvidovre Hospital; Department of orthopedic surgery, Sport Orthopedic Research Center – Copenhagen (SORC-C) , Hvidovre Hospital; Department of orthopedic surgery, Sport Orthopedic Research Center – Copenhagen (SORC-C) , Hvidovre Hospital
Background: For decades, the choice of operative or non- operative treatment of acute Achilles tendon rupture has been debated. Few studies present data on the difference in functional outcomes.
Purpose / Aim of Study: To compare functional outcomes in operative and non-operative treatment of acute Achilles tendon rupture.
Materials and Methods: The study was performed as a register study from the Danish Achilles tendon Database. The primary outcome was the Achilles Tendon Resting Angle (ATRA) 12 months post-injury. The secondary outcomes, assessed 12 months post-injury, were heel-rise height, Achilles tendon Total Rupture Score (ATRS), return to pre-injury work and sport, as well as satisfaction with the treatment and the result. Comparison between operative and non-operative treatment was performed using multiple linear and logistic regression analysis, controlling for sex, age, diabetes, rheumatism, hypertension, treatment with corticosteroids, hospital of treatment and age of the rupture.
Findings / Results: 364 patients were included in the study population from August 2016 to January 2019. ATRA showed a statistically significant difference of 1.67 degrees (CI: -2.83; -0.52; P = 0.0047) in favor of operative treatment. Also, operatively treated patients had statistically significantly better odds (odds ratio 2.2 (CI: 1.07; 4.72; P = 0.038)) of returning to the same type of sports. There was no statistically significant difference in heel-rise height, ATRS, return to pre-injury work or satisfaction with the result and treatment.
Conclusions: This study found a statistically significant difference in the primary outcome (ATRA) in favor of operative treatment compared to the non-operative. This difference is not considered clinically relevant.
Pelle Hanberg, Mats Bue, Kristina Öbrink-Hansen, Maja Thomassen, Kjeld Søballe, Maiken Stilling
Department of Orthopaedic Surgery, Horsens Regional Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Infectious Diseases, Aarhus University Hospital; Orthopaedic Research Unit, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital
Background: Tourniquet is widely used in orthopedic surgery in order to improve visualization and reduce perioperative bleeding. However, tourniquet has been associated with multiple adverse effects which may be related to the tourniquet induced ischemia.
Purpose / Aim of Study: We aimed to evaluate the ischemic metabolites in subcutaneous tissue and calcaneal cancellous bone before, during, and after tourniquet application.
Materials and Methods: Eight female pigs were included. Microdialysis catheters were placed for sampling of the ischemic markers glucose, lactate, pyruvate, and glycerol bilaterally in subcutaneous tissue and calcaneal cancellous bone. A tourniquet was applied on a randomly picked leg of each pig. Tourniquet inflation time was 15 min and the tourniquet duration was 90 min. Dialysates were collected for 8 hours.
Findings / Results: Shortly after tq inflation, a three-fold increase in the lactate/pyruvate ratio was found in both subcutaneous tissue and calcaneal cancellous bone. While the lactate/pyruvate ratio for subcutaneous tissue decreased to baseline immediately after tq release, the lactate/pyruvate ratio was normalized in calcaneal cancellous bone after 2.5 hours. Furthermore, calcaneal cancellous bone was exposed to a decreased glucose ratio and an increased glycerol ratio during tq application.
Conclusions: This study demonstrates that microdialysis can be used to monitor ischemic markers in the interstitial space of subcutaneous tissue and calcaneal cancellous bone. We found that tourniquet application induced ischemia and cell damage in subcutaneous tissue and calcaneal cancellous bone, which were fully recovered within 2.5 hours from tourniquet release.
Department of Orthopaedic Surgery, Horsens Regional Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Infectious Diseases, Aarhus University Hospital; Orthopaedic Research Unit, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital
Background: Tourniquet is widely used in orthopedic surgery in order to improve visualization and reduce perioperative bleeding. However, tourniquet has been associated with multiple adverse effects which may be related to the tourniquet induced ischemia.
Purpose / Aim of Study: We aimed to evaluate the ischemic metabolites in subcutaneous tissue and calcaneal cancellous bone before, during, and after tourniquet application.
Materials and Methods: Eight female pigs were included. Microdialysis catheters were placed for sampling of the ischemic markers glucose, lactate, pyruvate, and glycerol bilaterally in subcutaneous tissue and calcaneal cancellous bone. A tourniquet was applied on a randomly picked leg of each pig. Tourniquet inflation time was 15 min and the tourniquet duration was 90 min. Dialysates were collected for 8 hours.
Findings / Results: Shortly after tq inflation, a three-fold increase in the lactate/pyruvate ratio was found in both subcutaneous tissue and calcaneal cancellous bone. While the lactate/pyruvate ratio for subcutaneous tissue decreased to baseline immediately after tq release, the lactate/pyruvate ratio was normalized in calcaneal cancellous bone after 2.5 hours. Furthermore, calcaneal cancellous bone was exposed to a decreased glucose ratio and an increased glycerol ratio during tq application.
Conclusions: This study demonstrates that microdialysis can be used to monitor ischemic markers in the interstitial space of subcutaneous tissue and calcaneal cancellous bone. We found that tourniquet application induced ischemia and cell damage in subcutaneous tissue and calcaneal cancellous bone, which were fully recovered within 2.5 hours from tourniquet release.
Mads Holm Gude, Gudrun Holm Jacobsen, Per Hviid Gundtoft, Michael Brix, Mette Rosenstand, Bjarke Viberg
Ortopædkirurgisk afdeling, Kolding Sygehus; Ortopædkirurgisk afdeling, Kolding Sygehus; Ortopædkirurgisk afdeling, Kolding Sygehus; Ortopædkirurgisk afdeling, Odense Universitetshospital; Ortopædkirurgisk afdeling, Kolding Sygehus; Ortopædkirurgisk afdeling, Kolding Sygehus
Background: Tourniquet (TQ) is widely used in orthopaedic trauma surgery for better fracture visualization but there are complications directly related to its use. The evidence concerning the benefit or frequency of complications when using TQ is sparse.
Purpose / Aim of Study: The aim is to compare the risk of complications in TQ use or not in patients with surgical treated ankle fractures. Secondary to investigate whether surgical experience is associated with TQ use and the distribution of TQ use in Denmark.
Materials and Methods: The study is a population based register study from the Danish Fracture Database (DFDB). Data was extracted on patients with AO type 44 and primary internal fixation in the period March 15, 2012 to December 31, 2016. Primary outcome was major complications defined as re- osteosynthesis, amputation, deep infection, arthroplasty, and arthrodesis. Minor complications was defined as removal of osteosynthesis after more than 12 weeks. DFDB data was linked update with data from the Danish National Patient Registry for complete complication information. Multivariate regression analysis was performed for relative risk (RR) adjusted for age, sex, American Society of Anesthesiologists Classification (ASA) and level of surgeons experience. All results are reported with 95% confidence interval.
Findings / Results: There were 3,389 (83%) without TQ (non-TQ) and 669 (17%) with TQ. The average age was 53.5 years (52.9; 54.1), 61% were female and 89% had an ASA score of 2 or less with no statistical difference between the 2 groups. In the non-TQ group, 148 (4%) had major complications compared to 21 (3%) in the TQ group yielding an adjusted RR of 1.45 (0.91; 2.32). There were 791 (24%) minor complications in the non-TQ group compared to 165 (25%) in the TQ group yielding an adjusted RR of 0.99 (0.84; 1.17). Consultants predominantly used TQ during fracture surgery (p< 0.0001) and there was significant variance in inter-hospital use of TQ (p<0.0001) ranging from 0% to 43%.
Conclusions: There was no association between the use of TQ and minor or major complications. However, the use of TQ varied considerable between hospitals and with surgical experience. The potential benefit of TQ use should be considered in all hospitals.
Ortopædkirurgisk afdeling, Kolding Sygehus; Ortopædkirurgisk afdeling, Kolding Sygehus; Ortopædkirurgisk afdeling, Kolding Sygehus; Ortopædkirurgisk afdeling, Odense Universitetshospital; Ortopædkirurgisk afdeling, Kolding Sygehus; Ortopædkirurgisk afdeling, Kolding Sygehus
Background: Tourniquet (TQ) is widely used in orthopaedic trauma surgery for better fracture visualization but there are complications directly related to its use. The evidence concerning the benefit or frequency of complications when using TQ is sparse.
Purpose / Aim of Study: The aim is to compare the risk of complications in TQ use or not in patients with surgical treated ankle fractures. Secondary to investigate whether surgical experience is associated with TQ use and the distribution of TQ use in Denmark.
Materials and Methods: The study is a population based register study from the Danish Fracture Database (DFDB). Data was extracted on patients with AO type 44 and primary internal fixation in the period March 15, 2012 to December 31, 2016. Primary outcome was major complications defined as re- osteosynthesis, amputation, deep infection, arthroplasty, and arthrodesis. Minor complications was defined as removal of osteosynthesis after more than 12 weeks. DFDB data was linked update with data from the Danish National Patient Registry for complete complication information. Multivariate regression analysis was performed for relative risk (RR) adjusted for age, sex, American Society of Anesthesiologists Classification (ASA) and level of surgeons experience. All results are reported with 95% confidence interval.
Findings / Results: There were 3,389 (83%) without TQ (non-TQ) and 669 (17%) with TQ. The average age was 53.5 years (52.9; 54.1), 61% were female and 89% had an ASA score of 2 or less with no statistical difference between the 2 groups. In the non-TQ group, 148 (4%) had major complications compared to 21 (3%) in the TQ group yielding an adjusted RR of 1.45 (0.91; 2.32). There were 791 (24%) minor complications in the non-TQ group compared to 165 (25%) in the TQ group yielding an adjusted RR of 0.99 (0.84; 1.17). Consultants predominantly used TQ during fracture surgery (p< 0.0001) and there was significant variance in inter-hospital use of TQ (p<0.0001) ranging from 0% to 43%.
Conclusions: There was no association between the use of TQ and minor or major complications. However, the use of TQ varied considerable between hospitals and with surgical experience. The potential benefit of TQ use should be considered in all hospitals.
Christopher Jantzen, Lars B. Ebskov, Kim H. Andersen, Mostafa Benyahia, Peter Bro-Rasmusssen, Jens K. Johansen
Department of Orthopedic Surgery, Foot and Ankle Section, Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section, Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section, Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section, Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section, Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section, Hvidovre University Hospital, Copenhagen, Denmark
Background: Non-operative measures are often used as first line treatment in ankle osteoarthritis (OA). One of these measures consists of hyaluronic acid (HA) injections in the affected ankle joint but the efficiency of this treatment is uncertain with lacking evidence regarding both the effect and number of injections needed.
Purpose / Aim of Study: To evaluate the effect on Self-reported Foot and Ankle Score (SEFAS) score, visual analogue scale (VAS) score at rest and VAS score at activity prior to and 6 months after a single dose of HA in patients with grade I - IV OA of the ankle.
Materials and Methods: Patients above 18 years were included during the period December 2017 to Marts 2019. All patients were not interested in surgery and had tried other conservative measures without effect. Included patients received a single intra-articular injection of either Cingal (4 mL, 88 mg HA plus 18 mg triamcinolone hexacetonide) or MonoVisc (4 mL, 88 mg HA) in the affected ankle joint, with the latter being used in case of diabetes or surgeon preference. Age, gender, OA-grade, SEFAS-score, VAS at activity and at rest prior to injection and after 6 months was registered. Statistical analysis was conducted in SAS 9.4.
Findings / Results: A total of 33 patients were included in the study with 14 being lost to follow-up. As such, 19 patients (31.5 % men and 68.5 % women) with a median age of 55 (range 30-81) were included for analysis. Fifteen (79 %) were injected with Cingal and 4 (21%) with Monovisc. Median SEFAS-score remained unchanged at 21 (p=0.13) while VAS at activity went from 7 to 6 (0.003) and VAS at rest was reduced from 4 to 3 (0.03).
Conclusions: The unchanged SEFAS-score together with the minor changes in VAS at activity and at rest indicates that a single injection of HA might be insufficient to produce at clinical response after 6 months and further studies on the subject should focus on treatment protocols with multiple injections.
Department of Orthopedic Surgery, Foot and Ankle Section, Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section, Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section, Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section, Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section, Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section, Hvidovre University Hospital, Copenhagen, Denmark
Background: Non-operative measures are often used as first line treatment in ankle osteoarthritis (OA). One of these measures consists of hyaluronic acid (HA) injections in the affected ankle joint but the efficiency of this treatment is uncertain with lacking evidence regarding both the effect and number of injections needed.
Purpose / Aim of Study: To evaluate the effect on Self-reported Foot and Ankle Score (SEFAS) score, visual analogue scale (VAS) score at rest and VAS score at activity prior to and 6 months after a single dose of HA in patients with grade I - IV OA of the ankle.
Materials and Methods: Patients above 18 years were included during the period December 2017 to Marts 2019. All patients were not interested in surgery and had tried other conservative measures without effect. Included patients received a single intra-articular injection of either Cingal (4 mL, 88 mg HA plus 18 mg triamcinolone hexacetonide) or MonoVisc (4 mL, 88 mg HA) in the affected ankle joint, with the latter being used in case of diabetes or surgeon preference. Age, gender, OA-grade, SEFAS-score, VAS at activity and at rest prior to injection and after 6 months was registered. Statistical analysis was conducted in SAS 9.4.
Findings / Results: A total of 33 patients were included in the study with 14 being lost to follow-up. As such, 19 patients (31.5 % men and 68.5 % women) with a median age of 55 (range 30-81) were included for analysis. Fifteen (79 %) were injected with Cingal and 4 (21%) with Monovisc. Median SEFAS-score remained unchanged at 21 (p=0.13) while VAS at activity went from 7 to 6 (0.003) and VAS at rest was reduced from 4 to 3 (0.03).
Conclusions: The unchanged SEFAS-score together with the minor changes in VAS at activity and at rest indicates that a single injection of HA might be insufficient to produce at clinical response after 6 months and further studies on the subject should focus on treatment protocols with multiple injections.
Kristine Rask Andreasen, Maria Swennergren Hansen, Jesper Bencke, Kristoffer Weisskirchner Barfod, Per Hölmich
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Laboratory of Human Movement Analysis, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Sports Orthopedic Research Center – Copenhagen (SORC-C), Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Sports Orthopedic Research Center – Copenhagen (SORC-C), Copenhagen University Hospital Hvidovre
Background: The heel-rise work test is the most common outcome measure used for quantifying functional deficits after acute Achilles tendon rupture. The test is usually performed with use of a linear encoder, as introduced by Silbernagel et al. in 2010, but its validity is unknown.
Purpose / Aim of Study: The purpose of this study was to evaluate the concurrent validity of the heel-rise work test performed with use of a linear encoder.
Materials and Methods: The study was designed as a validity study performed on a prospective cohort of consecutive patients. Data was collected as part of an ongoing randomized controlled trial. A motion capture system was used as gold standard. The test was carried out with the participant standing on a wooden box with af 10-degree incline. The string of the linear encoder was attached to the participants heel. Reflective markers were attached to the heel and anatomical landmarks on the pelvis from which the pelvic center was calculated. The heel-rise work tests ability to detect total work is based on the assumption, that the heel is lifted as high as the center of body mass during a heel rise. The pelvic center was used to estimate the center of body mass, from which the true total work can be detected. The heel marker was used to quantify the measurement error, when the motion capture system was given the same prerequisites as the linear encoder. The heel-rise work test was carried out using the two measurement systems simultaneously.
Findings / Results: The linear encoder overestimated the total work with 22 % on the injured limb and 24 % on the non-injured limb, when compared to the pelvic centre (p < 0.0001). When compared to the heel markers, the measurement error was 1.5 % on the injured limb (p = 0.043) and 2.4 % on the non-injured limb (p < 0.0001). When comparing the limb symmetry index assessed by the linear encoder to the limb symmetry index assessed by the motion capture system, no differences was found.
Conclusions: The linear encoder was able to detect the relative differences between the injured and uninjured limb in an accurate manner but overestimated the absolute work with 22 %to 24 %.
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Laboratory of Human Movement Analysis, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Sports Orthopedic Research Center – Copenhagen (SORC-C), Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Sports Orthopedic Research Center – Copenhagen (SORC-C), Copenhagen University Hospital Hvidovre
Background: The heel-rise work test is the most common outcome measure used for quantifying functional deficits after acute Achilles tendon rupture. The test is usually performed with use of a linear encoder, as introduced by Silbernagel et al. in 2010, but its validity is unknown.
Purpose / Aim of Study: The purpose of this study was to evaluate the concurrent validity of the heel-rise work test performed with use of a linear encoder.
Materials and Methods: The study was designed as a validity study performed on a prospective cohort of consecutive patients. Data was collected as part of an ongoing randomized controlled trial. A motion capture system was used as gold standard. The test was carried out with the participant standing on a wooden box with af 10-degree incline. The string of the linear encoder was attached to the participants heel. Reflective markers were attached to the heel and anatomical landmarks on the pelvis from which the pelvic center was calculated. The heel-rise work tests ability to detect total work is based on the assumption, that the heel is lifted as high as the center of body mass during a heel rise. The pelvic center was used to estimate the center of body mass, from which the true total work can be detected. The heel marker was used to quantify the measurement error, when the motion capture system was given the same prerequisites as the linear encoder. The heel-rise work test was carried out using the two measurement systems simultaneously.
Findings / Results: The linear encoder overestimated the total work with 22 % on the injured limb and 24 % on the non-injured limb, when compared to the pelvic centre (p < 0.0001). When compared to the heel markers, the measurement error was 1.5 % on the injured limb (p = 0.043) and 2.4 % on the non-injured limb (p < 0.0001). When comparing the limb symmetry index assessed by the linear encoder to the limb symmetry index assessed by the motion capture system, no differences was found.
Conclusions: The linear encoder was able to detect the relative differences between the injured and uninjured limb in an accurate manner but overestimated the absolute work with 22 %to 24 %.
Niels Nedergaard, Per Hölmich, Jesper Bencke, Niels Christian Kaldau
Human Movement Analysis Laboratory, Department of Orthopedic Surgery, Amager-Hvidovre Hospital, Copenhagen, Denmark; Sports Orthopedic Research Center - Copenhagen, Department of Orthopedic Surgery, Amager-Hvidovre Hospital, Copenhagen, Denmark; Human Movement Analysis Laboratory, Department of Orthopedic Surgery, Amager-Hvidovre Hospital, Copenhagen, Denmark; Sports Orthopedic Research Center - Copenhagen, Department of Orthopedic Surgery, Amager-Hvidovre Hospital, Copenhagen, Denmark
Background: Achilles tendon (AT) rupture is common among recreational male badminton players. Observations indicate that AT ruptures often occur in the transition from landing to forward acceleration following a forehand stroke on the rear court. It is an observation that many recreational players use a different landing technique from elite players, and the hypothesis is that this result in higher AT forces and increased risk of sustaining an AT rupture.
Purpose / Aim of Study: The aim of this study was to explore the relationship between landing technique and AT forces in recreational badminton players during simulated rear court forehand strokes.
Materials and Methods: Ten recreational male badminton players (age: 28.1 ± 6.3 yr., height: 182.7 ± 5.9 cm, mass: 79.7 ± 10.5 kg) attended a single test session, where they performed 5 forehand rear court strokes with their usual technique jumping straight backwards, and 5 forehand strokes adopting the technique of elite players landing with the rear foot perpendicular to the direction of movement. AT force, of the leg opposite to the players’ racket arm, was calculated from 3D motion analysis. A multiple stepwise linear regression was performed to explore the relationship between peak AT force and four independent variables: peak dorsiflexion (DF), outwards foot position (Fpos), vertical ground reaction force (vGRF) and average forward velocity (Fvel).
Findings / Results: The stepwise regression analysis generated three models. DF had the largest Pearson correlation (r = 0.39) and was therefore included in Model A (R2 = 0.15). The combination of DF, Fvel and Fpos could account for 39% of the variance in AT force. Similar standardized beta-weights (0.32-0.36) were observed for DF, Fvel and Fpos, and all three were significant (p<0.05) predictors of the peak AT force.
Conclusions: Landing from a rear court forehand stroke with large dorsiflexion or with a neutral foot position, or with increased forward acceleration upon landing, are all equally associated with increased AT forces. These findings indicate that recreational players may reduce the high loads on their AT by adopting the landing technique of elite players, and potentially reduce the risk of sustaining an AT rupture.
Human Movement Analysis Laboratory, Department of Orthopedic Surgery, Amager-Hvidovre Hospital, Copenhagen, Denmark; Sports Orthopedic Research Center - Copenhagen, Department of Orthopedic Surgery, Amager-Hvidovre Hospital, Copenhagen, Denmark; Human Movement Analysis Laboratory, Department of Orthopedic Surgery, Amager-Hvidovre Hospital, Copenhagen, Denmark; Sports Orthopedic Research Center - Copenhagen, Department of Orthopedic Surgery, Amager-Hvidovre Hospital, Copenhagen, Denmark
Background: Achilles tendon (AT) rupture is common among recreational male badminton players. Observations indicate that AT ruptures often occur in the transition from landing to forward acceleration following a forehand stroke on the rear court. It is an observation that many recreational players use a different landing technique from elite players, and the hypothesis is that this result in higher AT forces and increased risk of sustaining an AT rupture.
Purpose / Aim of Study: The aim of this study was to explore the relationship between landing technique and AT forces in recreational badminton players during simulated rear court forehand strokes.
Materials and Methods: Ten recreational male badminton players (age: 28.1 ± 6.3 yr., height: 182.7 ± 5.9 cm, mass: 79.7 ± 10.5 kg) attended a single test session, where they performed 5 forehand rear court strokes with their usual technique jumping straight backwards, and 5 forehand strokes adopting the technique of elite players landing with the rear foot perpendicular to the direction of movement. AT force, of the leg opposite to the players’ racket arm, was calculated from 3D motion analysis. A multiple stepwise linear regression was performed to explore the relationship between peak AT force and four independent variables: peak dorsiflexion (DF), outwards foot position (Fpos), vertical ground reaction force (vGRF) and average forward velocity (Fvel).
Findings / Results: The stepwise regression analysis generated three models. DF had the largest Pearson correlation (r = 0.39) and was therefore included in Model A (R2 = 0.15). The combination of DF, Fvel and Fpos could account for 39% of the variance in AT force. Similar standardized beta-weights (0.32-0.36) were observed for DF, Fvel and Fpos, and all three were significant (p<0.05) predictors of the peak AT force.
Conclusions: Landing from a rear court forehand stroke with large dorsiflexion or with a neutral foot position, or with increased forward acceleration upon landing, are all equally associated with increased AT forces. These findings indicate that recreational players may reduce the high loads on their AT by adopting the landing technique of elite players, and potentially reduce the risk of sustaining an AT rupture.
Jens K. Johansen, Kim H. Andersen, Christopher Jantzen, Mostafa Benyahia, Peter Bro-Rasmussen, Lars B. Ebskov
Department of Orthopedic Surgery, Foot and Ankle Section , Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section , Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section , Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section , Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section , Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section , Hvidovre University Hospital, Copenhagen, Denmark
Background: Osteochondral defects (OCDs) of the talus represents a surgical challenge. Primary OCDs with a size less than 150 mm2 /15 mm in diameter, without large cyst formation or other complicating factors can be treated with simple arthroscopic bone marrow stimulation techniques. When confronted with more complex OCDs a HemiCAP metal resurfacing implant of talus might be an option but few follow-up studies exist.
Purpose / Aim of Study: To evaluate the mid-term results after HemiCAP implantation in patients with complex OCDs during the period 2008-2016.
Materials and Methods: Patients were included during the period 2008- 2016. Inclusion criteria’s were: OCD of the medial or lateral talar dome, symptoms for >1 year since last surgery, OCD treated at least 1 year conservatively without effect. Exclusion criteria’s were: defects larger than 20 mm, ankle osteoarthritis Grade >II or other ankle pathology, known allergy to implant material or diabetes. Outcome measures were the American Orthopaedic Foot and Ankle Society Score, the Numerical Rating Scale, Foot and Ankle Outcome Score, sports participation, work level and radiographic evaluation. Implant survival, defined as the implant remaining in situ without revision to total ankle arthroplasty, ankle fusion or removal of the implant was evaluated as well.
Findings / Results: 31 patients were included during the period with a mean follow-up of 50 months (11.5 – 81.4). All outcome measures improved significantly. Only one patient had an complication registered which were an infection treated with antibiotics. 13 patients (41,9 %) had an additional procedure performed (eg. arthroscopic debridement, hardware removal, cheilectomy) with none of the patients being revised.
Conclusions: The primary aim of OCD treatment is to reduce pain, and this is achieved with the HemiCAP implant in patients with complex OCDs even tough patient information and selection is mandatory due to the relative high numbers of additional surgery following the HemiCap implantation.
Department of Orthopedic Surgery, Foot and Ankle Section , Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section , Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section , Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section , Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section , Hvidovre University Hospital, Copenhagen, Denmark; Department of Orthopedic Surgery, Foot and Ankle Section , Hvidovre University Hospital, Copenhagen, Denmark
Background: Osteochondral defects (OCDs) of the talus represents a surgical challenge. Primary OCDs with a size less than 150 mm2 /15 mm in diameter, without large cyst formation or other complicating factors can be treated with simple arthroscopic bone marrow stimulation techniques. When confronted with more complex OCDs a HemiCAP metal resurfacing implant of talus might be an option but few follow-up studies exist.
Purpose / Aim of Study: To evaluate the mid-term results after HemiCAP implantation in patients with complex OCDs during the period 2008-2016.
Materials and Methods: Patients were included during the period 2008- 2016. Inclusion criteria’s were: OCD of the medial or lateral talar dome, symptoms for >1 year since last surgery, OCD treated at least 1 year conservatively without effect. Exclusion criteria’s were: defects larger than 20 mm, ankle osteoarthritis Grade >II or other ankle pathology, known allergy to implant material or diabetes. Outcome measures were the American Orthopaedic Foot and Ankle Society Score, the Numerical Rating Scale, Foot and Ankle Outcome Score, sports participation, work level and radiographic evaluation. Implant survival, defined as the implant remaining in situ without revision to total ankle arthroplasty, ankle fusion or removal of the implant was evaluated as well.
Findings / Results: 31 patients were included during the period with a mean follow-up of 50 months (11.5 – 81.4). All outcome measures improved significantly. Only one patient had an complication registered which were an infection treated with antibiotics. 13 patients (41,9 %) had an additional procedure performed (eg. arthroscopic debridement, hardware removal, cheilectomy) with none of the patients being revised.
Conclusions: The primary aim of OCD treatment is to reduce pain, and this is achieved with the HemiCAP implant in patients with complex OCDs even tough patient information and selection is mandatory due to the relative high numbers of additional surgery following the HemiCap implantation.
Thomas Vedste Aagaard, Sahar Moeini, Søren Thorgaard Skou, Ulla Riis Madsen, Stig Brorson
Department of physo- and occupational therapy, Holbaek hospital; Department of Orthopaedic Surgery, Zealand University Hospital; Department of Physiotherapy and Occupational Therapy, Naestved-Slagelse-Ringsted Hospitals; Department of Orthopaedic Surgery, Holbaek Hospital; Department of Orthopaedic Surgery, Zealand University Hospital
Background: One of the most feared complications of diabetes mellitus is diabetic foot ulcers (DFU), as it can cause severe adverse consequences such as amputation or death. Patients are often required to refrain from bearing weight on their affected limb, leaving some patients immobile for weeks, months or even years. This is in direct contrast to guidelines for diabetes where exercise therapy and physical activity are core elements in the treatment. This leaves patients and caretakers with a paradox. If a DFU evolves, should patients continue following the guidelines for diabetes? Even if these guidelines include recommendations of brisk walking and exercising at high intensity.
Purpose / Aim of Study: Exercise therapy is a core element in the treatment of diabetes, but the benefits and harms for patients with a diabetic foot ulcer are unknown. We aimed to systematically review the benefits and harms of exercise therapy for patients with DFU.
Materials and Methods: We searched six major databases. We performed citation and reference searches of included studies and contacted authors of ongoing trials. We included randomized controlled trials to assess potential benefits on health-related quality of life (HRQoL) and harms of exercise therapy. Observational studies were included to identify potential harms of exercise therapy.
Findings / Results: We included 10 published publications of 9 trials and results from two unpublished trials including a total of 281 individuals with DFUs receiving various forms of exercise therapy. Due to lack of HRQoL measurements and high heterogeneity, it was not possible to perform meta-analyses. Results on HRQoL was present in one unpublished study. Harms reported ranged from musculoskeletal problems, increased wound size, to amputation; however, no safe conclusions could be drawn from the available data due to high heterogeneity and risk of bias in the trials.
Conclusions: Protective strategies are often preferred over therapeutic exercise which might have unforeseen consequences for patients over time. Based on the current literature, no evidence-based recommendations can be provided on the benefits and harms of exercise therapy for patients with DFUs. Well-conducted RCTs are needed to guide rehabilitation.
Department of physo- and occupational therapy, Holbaek hospital; Department of Orthopaedic Surgery, Zealand University Hospital; Department of Physiotherapy and Occupational Therapy, Naestved-Slagelse-Ringsted Hospitals; Department of Orthopaedic Surgery, Holbaek Hospital; Department of Orthopaedic Surgery, Zealand University Hospital
Background: One of the most feared complications of diabetes mellitus is diabetic foot ulcers (DFU), as it can cause severe adverse consequences such as amputation or death. Patients are often required to refrain from bearing weight on their affected limb, leaving some patients immobile for weeks, months or even years. This is in direct contrast to guidelines for diabetes where exercise therapy and physical activity are core elements in the treatment. This leaves patients and caretakers with a paradox. If a DFU evolves, should patients continue following the guidelines for diabetes? Even if these guidelines include recommendations of brisk walking and exercising at high intensity.
Purpose / Aim of Study: Exercise therapy is a core element in the treatment of diabetes, but the benefits and harms for patients with a diabetic foot ulcer are unknown. We aimed to systematically review the benefits and harms of exercise therapy for patients with DFU.
Materials and Methods: We searched six major databases. We performed citation and reference searches of included studies and contacted authors of ongoing trials. We included randomized controlled trials to assess potential benefits on health-related quality of life (HRQoL) and harms of exercise therapy. Observational studies were included to identify potential harms of exercise therapy.
Findings / Results: We included 10 published publications of 9 trials and results from two unpublished trials including a total of 281 individuals with DFUs receiving various forms of exercise therapy. Due to lack of HRQoL measurements and high heterogeneity, it was not possible to perform meta-analyses. Results on HRQoL was present in one unpublished study. Harms reported ranged from musculoskeletal problems, increased wound size, to amputation; however, no safe conclusions could be drawn from the available data due to high heterogeneity and risk of bias in the trials.
Conclusions: Protective strategies are often preferred over therapeutic exercise which might have unforeseen consequences for patients over time. Based on the current literature, no evidence-based recommendations can be provided on the benefits and harms of exercise therapy for patients with DFUs. Well-conducted RCTs are needed to guide rehabilitation.
Jesper Bencke, Mette Kreutzfeldt Zebis
Department of Orthopaedic Surgery, Copenhagen University Hospital; Department of Midwifery, Physiotherapy, Occupational Therapy and Psychomotor Therapy Physiotherapy, University College Copenhagen
Background: Standing postural control has often been used as a measure of stability and a potential indicator of lower limb injury risk. Yet, acute injuries like ankle sprains happen within the first few milliseconds after contact, and dynamic landing tests might have a better potential for injury risk after rehabilitation.
Purpose / Aim of Study: To examine the reliability of a new parameter of landing stability in a group of young recreational athletes.
Materials and Methods: 11 subjects (3 female) volunteered to participate and were tested twice, one week apart. The subjects were instructed to jump a distance equal to 100% of leg length and land on a force plate as stable as possible and remain still for 5 seconds. The resultant centre of pressure (CoP) was measured at 200 Hz, and the distance of CoP translation was calculated in epochs of 200 ms during the first second. The average of 3 landings on the preferred jump leg was calculated. The Student t-test for paired samples was used to identify systematic error in the test- retest measurements (p < 0.05). Intraclass Correlation Coefficient (ICC3,k) was determined for relative reliability, while Coefficients of Variance (CV) were determined for absolute reliability.
Findings / Results: The distance of the CoP was highest during the initial 200 ms and rapidly declined and levelled during the last 400 ms. No differences from test to retest was found in any time epoch. The reliability was good in the first 200 ms (ICC200: 0.843 (0.42- 0.96) 95% CI), p=0.004, CV= 10.4% (7.4-16.4)), but was poor and non-significant from 200-600 ms. In the last two time-epochs reliability was fair and good, respectively (ICC800: 0.70 (-0.14-0.92), p=0.037, CV=27.9% (20.6-44.1); ICC1000: 0.80, (0.24-0.95), p=0.01, CV=18.4% (14.4-29.5)).
Conclusions: This new approach to quantifying landing stability showed good perspectives as an evaluation tool, both the initial landing stability measure, as well as for the stability epochs 600-1000 ms after landing. The early stability may be most useful to evaluate risk of lower limb injury, since injuries occur in this early time period after landing. However, the relatively large CV indicates that it may be most useful for group interventions and less useful for individual feedback.
Department of Orthopaedic Surgery, Copenhagen University Hospital; Department of Midwifery, Physiotherapy, Occupational Therapy and Psychomotor Therapy Physiotherapy, University College Copenhagen
Background: Standing postural control has often been used as a measure of stability and a potential indicator of lower limb injury risk. Yet, acute injuries like ankle sprains happen within the first few milliseconds after contact, and dynamic landing tests might have a better potential for injury risk after rehabilitation.
Purpose / Aim of Study: To examine the reliability of a new parameter of landing stability in a group of young recreational athletes.
Materials and Methods: 11 subjects (3 female) volunteered to participate and were tested twice, one week apart. The subjects were instructed to jump a distance equal to 100% of leg length and land on a force plate as stable as possible and remain still for 5 seconds. The resultant centre of pressure (CoP) was measured at 200 Hz, and the distance of CoP translation was calculated in epochs of 200 ms during the first second. The average of 3 landings on the preferred jump leg was calculated. The Student t-test for paired samples was used to identify systematic error in the test- retest measurements (p < 0.05). Intraclass Correlation Coefficient (ICC3,k) was determined for relative reliability, while Coefficients of Variance (CV) were determined for absolute reliability.
Findings / Results: The distance of the CoP was highest during the initial 200 ms and rapidly declined and levelled during the last 400 ms. No differences from test to retest was found in any time epoch. The reliability was good in the first 200 ms (ICC200: 0.843 (0.42- 0.96) 95% CI), p=0.004, CV= 10.4% (7.4-16.4)), but was poor and non-significant from 200-600 ms. In the last two time-epochs reliability was fair and good, respectively (ICC800: 0.70 (-0.14-0.92), p=0.037, CV=27.9% (20.6-44.1); ICC1000: 0.80, (0.24-0.95), p=0.01, CV=18.4% (14.4-29.5)).
Conclusions: This new approach to quantifying landing stability showed good perspectives as an evaluation tool, both the initial landing stability measure, as well as for the stability epochs 600-1000 ms after landing. The early stability may be most useful to evaluate risk of lower limb injury, since injuries occur in this early time period after landing. However, the relatively large CV indicates that it may be most useful for group interventions and less useful for individual feedback.