Session 7: Tumor, amputation and Infection
16. November
09:30 - 11:00
Lokale: 102-105
Chair: Tine Nymark and Klaus K Petersen
Hans Christian Rasmussen1, Maiken Stilling1,2, Johanne Lilleøre1, Elisabeth Petersen1, Magnus Hvistendahl1, Andrea Jørgensen1, Pelle Hanberg1,3, Mats Bue1,2
1. Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital; 2. Dept. of Orthopaedics, Aarhus University Hospital; 3. Dept. of Head and Neck Surgery, Aarhus University Hospital.
Background: The ß-lactam penicillin is often used in the treatment of soft tissue infections and osteomyelitis caused by penicillin susceptible Staph. aureus. Oral antibiotic treatment has been shown to be non-inferior to intravenous (IV) therapy when used during the first 6 weeks in complex orthopaedic infections (OVIVAtrial). However, the use of oral ß-lactams in osteomyelitis treatment remains a topic of debate due to low and variable bioavailability.
Aim: Assess the time for which the unbound penicillin concentration exceeded targeted minimum inhibitory concentrations (fT>MIC) in cancellous bone and subcutaneous tissue after IV (penicillin G) and oral (penicillin V) treatment in a porcine microdialysis model.
Materials and Methods: 12 pigs (75kg) were assigned to standard clinical regimens of either three doses of IV penicillin G (1.2g) or oral penicillin V (0.8g) every 6h over 18h. Microdialysis catheters were placed for sampling in tibial cancellous bone and adjacent subcutaneous tissue. Data was collected in the first dosing interval (0-6h; prophylactic situation) and the third dosing interval (12-18h; assumed steady state). Plasma samples were collected for reference. MIC targets of 0.125µg/mL (S. aureus breakpoint), 0.25µg/mL (Strep. Group A, B, C and G breakpoint) and 0.5µg/mL (4xMIC) were applied.
Results: For all MIC targets, IV penicillin G resulted in a longer mean fT>MIC in cancellous bone during the first dosing interval, and in both cancellous bone and subcutaneous tissue during the third dosing interval compared to oral penicillin V. Across compartments, mean fT>MIC for IV penicillin G (MIC: 0.125, 0.25 and 0.5µg/mL) were =97%, =84% and =75% during the first dosing interval, and 100%, =95% and =88%, during the third dosing interval. The mean fT>MIC for oral penicillin V were =40%, =24% and =7% during the first dosing interval, and =42%, =36% and =18% during the third dosing interval.
Interpretation / Conclusion: The findings suggest that standard clinical dosing of IV penicillin G provides superior fT>MIC in cancellous bone and subcutaneous tissue compared to oral penicillin V, particularly in the third dosing interval. This emphasizes the importance of appropriate route of administration when applying penicillin treatment.
1. Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital; 2. Dept. of Orthopaedics, Aarhus University Hospital; 3. Dept. of Head and Neck Surgery, Aarhus University Hospital.
Background: The ß-lactam penicillin is often used in the treatment of soft tissue infections and osteomyelitis caused by penicillin susceptible Staph. aureus. Oral antibiotic treatment has been shown to be non-inferior to intravenous (IV) therapy when used during the first 6 weeks in complex orthopaedic infections (OVIVAtrial). However, the use of oral ß-lactams in osteomyelitis treatment remains a topic of debate due to low and variable bioavailability.
Aim: Assess the time for which the unbound penicillin concentration exceeded targeted minimum inhibitory concentrations (fT>MIC) in cancellous bone and subcutaneous tissue after IV (penicillin G) and oral (penicillin V) treatment in a porcine microdialysis model.
Materials and Methods: 12 pigs (75kg) were assigned to standard clinical regimens of either three doses of IV penicillin G (1.2g) or oral penicillin V (0.8g) every 6h over 18h. Microdialysis catheters were placed for sampling in tibial cancellous bone and adjacent subcutaneous tissue. Data was collected in the first dosing interval (0-6h; prophylactic situation) and the third dosing interval (12-18h; assumed steady state). Plasma samples were collected for reference. MIC targets of 0.125µg/mL (S. aureus breakpoint), 0.25µg/mL (Strep. Group A, B, C and G breakpoint) and 0.5µg/mL (4xMIC) were applied.
Results: For all MIC targets, IV penicillin G resulted in a longer mean fT>MIC in cancellous bone during the first dosing interval, and in both cancellous bone and subcutaneous tissue during the third dosing interval compared to oral penicillin V. Across compartments, mean fT>MIC for IV penicillin G (MIC: 0.125, 0.25 and 0.5µg/mL) were =97%, =84% and =75% during the first dosing interval, and 100%, =95% and =88%, during the third dosing interval. The mean fT>MIC for oral penicillin V were =40%, =24% and =7% during the first dosing interval, and =42%, =36% and =18% during the third dosing interval.
Interpretation / Conclusion: The findings suggest that standard clinical dosing of IV penicillin G provides superior fT>MIC in cancellous bone and subcutaneous tissue compared to oral penicillin V, particularly in the third dosing interval. This emphasizes the importance of appropriate route of administration when applying penicillin treatment.
Armita Armina Abedi1,2,3, Jacob Moflag Svensson1, Alma Becic Pedersen4,5, Claus Varnum 6,7, Sabrina Mai Nielsen 3,8, Jens Holm Laigaard1,2, Robin Christensen3,8, Søren Overgaard1,2
1. Department of Orthopedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg, Denmark; 2. Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; 3. Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Denmark; 4. Department of Clinical Epidemiology, Aarhus University Hospital, Denmark; 5. Department of Clinical Medicine, Aarhus University, Denmark; 6. Department of Orthopedics, Lillebaelt Hospital, Vejle, Denmark; 7. Department of Regional Health Research, University of Southern Denmark, Denmark; 8. Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Denmark.
Background: Perioperative antibiotic prophylaxis (AB) is a routine in THA to reduce the risk of surgical site infections. However, it remains unclear whether there exists a superior AB practice approach in prevention of postoperative serious adverse events (SAEs).
Aim: To compare the relative effectiveness of different AB prophylaxis approaches in prevention of SAEs up to one year after the THA.
Materials and Methods: The study was designed as a systematic review and network meta-analysis of randomized trials (RCT). Data sources were MEDLINE, EMBASE and Cochrane Library to identify RCTs that examined the effect of AB prophylaxis in patients = 18 years, receiving primary THA. SAE was defined as a composite of prosthetic joint infections, other serious infections, major cardiovascular events, venous thromboembolisms, and mortality. Our network meta-analysis was based on mixed-effects logistic regression. The odds ratio (OR) with 95% confidence interval was the primary measure of association.
Results: We screened 6,221 records for eligibility and included 10 trials (9,130 patients) for analysis. Trial arms were divided into five groups: placebo (3), single-dose (3), multiple doses up to 24 hours (6), and multiple doses >1 day (6), and AB cementation practice (2). Compared to placebo, all AB prophylaxis practices were superior in reducing the odds of having an SAE up to 1 year after surgery: OR (single-dose) = 0.16 (0.03 – 0.71), OR (multiple doses up to 24 hours) = 0.13 (0.03 – 0.48), OR (multiple doses >1 day) = 0.22 (0.07 – 0.71) and OR (AB cementation) = 0.06 (0.01 – 0.36). There was no evidence suggesting that a single-dose AB was inferior to multiple doses up to 24 hours (OR = 1.22 (0.40 – 3.70)) nor multiple doses >1 day (OR = 0.70 (0.19 – 2.54)). Furtheremore, there was no evidence suggesting that AB practice with multiple doses up to 24 hours was inferior to multiple doses >1 day, (OR=0.58 (0.20 – 1.67)).
Interpretation / Conclusion: Evidence from RCTs show that AB is effective in prevention of SAEs up to 1 year after THA. However, we could not confirm that any specific AB regime was superior. Thus, there is currently no evidence to suggest a preferable AB strategy.
1. Department of Orthopedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg, Denmark; 2. Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; 3. Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Denmark; 4. Department of Clinical Epidemiology, Aarhus University Hospital, Denmark; 5. Department of Clinical Medicine, Aarhus University, Denmark; 6. Department of Orthopedics, Lillebaelt Hospital, Vejle, Denmark; 7. Department of Regional Health Research, University of Southern Denmark, Denmark; 8. Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Denmark.
Background: Perioperative antibiotic prophylaxis (AB) is a routine in THA to reduce the risk of surgical site infections. However, it remains unclear whether there exists a superior AB practice approach in prevention of postoperative serious adverse events (SAEs).
Aim: To compare the relative effectiveness of different AB prophylaxis approaches in prevention of SAEs up to one year after the THA.
Materials and Methods: The study was designed as a systematic review and network meta-analysis of randomized trials (RCT). Data sources were MEDLINE, EMBASE and Cochrane Library to identify RCTs that examined the effect of AB prophylaxis in patients = 18 years, receiving primary THA. SAE was defined as a composite of prosthetic joint infections, other serious infections, major cardiovascular events, venous thromboembolisms, and mortality. Our network meta-analysis was based on mixed-effects logistic regression. The odds ratio (OR) with 95% confidence interval was the primary measure of association.
Results: We screened 6,221 records for eligibility and included 10 trials (9,130 patients) for analysis. Trial arms were divided into five groups: placebo (3), single-dose (3), multiple doses up to 24 hours (6), and multiple doses >1 day (6), and AB cementation practice (2). Compared to placebo, all AB prophylaxis practices were superior in reducing the odds of having an SAE up to 1 year after surgery: OR (single-dose) = 0.16 (0.03 – 0.71), OR (multiple doses up to 24 hours) = 0.13 (0.03 – 0.48), OR (multiple doses >1 day) = 0.22 (0.07 – 0.71) and OR (AB cementation) = 0.06 (0.01 – 0.36). There was no evidence suggesting that a single-dose AB was inferior to multiple doses up to 24 hours (OR = 1.22 (0.40 – 3.70)) nor multiple doses >1 day (OR = 0.70 (0.19 – 2.54)). Furtheremore, there was no evidence suggesting that AB practice with multiple doses up to 24 hours was inferior to multiple doses >1 day, (OR=0.58 (0.20 – 1.67)).
Interpretation / Conclusion: Evidence from RCTs show that AB is effective in prevention of SAEs up to 1 year after THA. However, we could not confirm that any specific AB regime was superior. Thus, there is currently no evidence to suggest a preferable AB strategy.
Rehne Lessmann Hansen1, Anette Marianne Fedder2, Hans Michael Betsch3, Karen Rokkedal Lausch4, Mette Holm5, Rikke Bek Helmig6, Mikala Wang7, Peter Christensen8, Per Hviid Gundtoft11, Klaus Kjær Petersen1
1: Department of Orthopaedic Surgery, Aarhus University Hospital 2: Department of Emergency Medicine, Aarhus University Hospital 3: Department of Intensive Care Medicine, Aarhus University Hospital 4: Department of Infectious Diseases, Aarhus University Hospital 5: Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital 6: Department of Obstetrics and Gynaecology, Aarhus University Hospital 7: Department of Clinical Microbiology, Aarhus University Hospital 8: Department of Surgery, Aarhus University Hospital
Background: Necrotizing Soft Tissue Infection (NSTI) is a rapidly progressing and potentially life- threatening soft tissue infection. Early diagnosis and prompt surgical intervention are crucial for improving patient outcomes.
Aim: To evaluate the impact of implementing a local/regional guideline for the treatment of NSTI.
Materials and Methods: At Aarhus University Hospital (AUH), a guideline for treating NSTI was introduced in 2020. A retrospective analysis of patients treated for NSTI at AUH from 2015 to 2020 (retro-group n=65) was conducted. From 2020 to 2023 data was collected prospectively in a local database (pro-group n=44). Clinical, laboratory, and surgical data were collected and analyzed using the electronic medical record.
Results: A total of 109 patients (61 men, 48 women) with a mean age of 61 years (SD 15.2) were included. Diabetes was the most frequent comorbidity (32%), followed by liver disease (6%) and cancer (8%). At the time of admission, the median CRP was 298.5 mg/L (IQR 187 to 389), leukocyte count 15.2 × 10^9/L (IQR 11.9 to 21), creatinine 110 µmol/L (IQR 75 to 155), and lactate levels were 2.45 mmol/L (IQR 1.3 to 4.2). 48% of the patients received pre-operative CT-scans, with no difference between the groups (p=0.72) The median time from suspicion of NSTI to surgical intervention was 90 minutes (IQR 35 to 209 minutes) in the retro-group and 79 minutes (IQR 54 to 137) in the pro-group (p=0.9) The most common bacteria isolated from tissue-samples were S. aureus, S. pyogenes, and Peptostreptococcus sp. 95% of patients were treated at the intensive care unit. The median SAP3-score was 56 (IQR 48 to 71), which correlated negatively with time to death (spearmans rho -0.62, p=0.045). 29 patients in the retro-group and 1 patient in the pro-group received hyperbaric oxygen treatment (P=0.005). 20 patients in the retro-group and 13 in the pro-group died after a median of 15 days (IQR 2 to 271) (p=0.68).
Interpretation / Conclusion: Our results show an overall short time from suspicion of NSTI to intervention. The preliminary results find that the implementation of a NSTI guideline has not had a significant effect on time- delay to surgical intervention or short-term survival.
1: Department of Orthopaedic Surgery, Aarhus University Hospital 2: Department of Emergency Medicine, Aarhus University Hospital 3: Department of Intensive Care Medicine, Aarhus University Hospital 4: Department of Infectious Diseases, Aarhus University Hospital 5: Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital 6: Department of Obstetrics and Gynaecology, Aarhus University Hospital 7: Department of Clinical Microbiology, Aarhus University Hospital 8: Department of Surgery, Aarhus University Hospital
Background: Necrotizing Soft Tissue Infection (NSTI) is a rapidly progressing and potentially life- threatening soft tissue infection. Early diagnosis and prompt surgical intervention are crucial for improving patient outcomes.
Aim: To evaluate the impact of implementing a local/regional guideline for the treatment of NSTI.
Materials and Methods: At Aarhus University Hospital (AUH), a guideline for treating NSTI was introduced in 2020. A retrospective analysis of patients treated for NSTI at AUH from 2015 to 2020 (retro-group n=65) was conducted. From 2020 to 2023 data was collected prospectively in a local database (pro-group n=44). Clinical, laboratory, and surgical data were collected and analyzed using the electronic medical record.
Results: A total of 109 patients (61 men, 48 women) with a mean age of 61 years (SD 15.2) were included. Diabetes was the most frequent comorbidity (32%), followed by liver disease (6%) and cancer (8%). At the time of admission, the median CRP was 298.5 mg/L (IQR 187 to 389), leukocyte count 15.2 × 10^9/L (IQR 11.9 to 21), creatinine 110 µmol/L (IQR 75 to 155), and lactate levels were 2.45 mmol/L (IQR 1.3 to 4.2). 48% of the patients received pre-operative CT-scans, with no difference between the groups (p=0.72) The median time from suspicion of NSTI to surgical intervention was 90 minutes (IQR 35 to 209 minutes) in the retro-group and 79 minutes (IQR 54 to 137) in the pro-group (p=0.9) The most common bacteria isolated from tissue-samples were S. aureus, S. pyogenes, and Peptostreptococcus sp. 95% of patients were treated at the intensive care unit. The median SAP3-score was 56 (IQR 48 to 71), which correlated negatively with time to death (spearmans rho -0.62, p=0.045). 29 patients in the retro-group and 1 patient in the pro-group received hyperbaric oxygen treatment (P=0.005). 20 patients in the retro-group and 13 in the pro-group died after a median of 15 days (IQR 2 to 271) (p=0.68).
Interpretation / Conclusion: Our results show an overall short time from suspicion of NSTI to intervention. The preliminary results find that the implementation of a NSTI guideline has not had a significant effect on time- delay to surgical intervention or short-term survival.
Anja Løve Berger1, Morten Tange Kristensen1,2
1. Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg-Frederiksberg and Department of Clinical Medicine, University of Copenhagen, Denmark 2. Departments of Physiotherapy and Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark
Background: Patients with a major dysvascular lower extremity amputation (LEA) are characterized by multimorbidity and high risk of mortality. Early mobilization, physiotherapy (PT) and achieving independent mobility are key components in enhanced recovery programs also for these patients, but often challenged by lack of compliance. However, knowledge of factors limiting early mobility and participating in PT after LEA is sparse.
Aim: To investigate patient reported factors limiting the ability to achieve independency in basic mobility and participate in the planned PT during the first 3 days of PT after LEA.
Materials and Methods: A total of 60 consecutive patients with a mean (SD) age of 73.7 (12.1) years that underwent a LEA within a 7-month period and treated according to an enhanced program at a university hospital were included. The Basic Amputee Mobility Score (BAMS, 0-8 points) was used to evaluate the patient’s independency in 4 basic mobility activities: 1) getting from lying to sitting in bed, 2) transfer from bed to wheelchair, 3) indoor wheelchair mobility, and 4) from wheelchair to standing on the non- amputated leg. Pre-defined limitations for not achieving a full BAMS score or inability to complete planned PT were: residual limb pain, pain elsewhere, fear of being mobilized, fatigue, nausea, acute cognitive dysfunction, or other, and noted on the first 3 days of PT.
Results: PT was started median postoperative Day1. Only 5 patients were independent in BAMS activity 2: transfer from bed to wheelchair, on PT Day1. Primary limiting factors for the 55 patients not independent were fatigue (44%) and fear of being mobilized (33%). 36 patients completed the planned PT on Day1, with the primary limiting factors for non-compliers being fatigue (38%) and pain in the residual limb (24%).
Interpretation / Conclusion: Fatigue and fear of being mobilized were the most frequent limiting factors for independent mobilization out of bed after LEA. Correspondingly, fatigue and pain in the residual limb restricted participation in the planned PT. These findings can be utilized in a multimodal perioperative setting to optimize treatment for overcoming these barriers, potentially leading to better compliance and outcomes.
1. Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg-Frederiksberg and Department of Clinical Medicine, University of Copenhagen, Denmark 2. Departments of Physiotherapy and Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark
Background: Patients with a major dysvascular lower extremity amputation (LEA) are characterized by multimorbidity and high risk of mortality. Early mobilization, physiotherapy (PT) and achieving independent mobility are key components in enhanced recovery programs also for these patients, but often challenged by lack of compliance. However, knowledge of factors limiting early mobility and participating in PT after LEA is sparse.
Aim: To investigate patient reported factors limiting the ability to achieve independency in basic mobility and participate in the planned PT during the first 3 days of PT after LEA.
Materials and Methods: A total of 60 consecutive patients with a mean (SD) age of 73.7 (12.1) years that underwent a LEA within a 7-month period and treated according to an enhanced program at a university hospital were included. The Basic Amputee Mobility Score (BAMS, 0-8 points) was used to evaluate the patient’s independency in 4 basic mobility activities: 1) getting from lying to sitting in bed, 2) transfer from bed to wheelchair, 3) indoor wheelchair mobility, and 4) from wheelchair to standing on the non- amputated leg. Pre-defined limitations for not achieving a full BAMS score or inability to complete planned PT were: residual limb pain, pain elsewhere, fear of being mobilized, fatigue, nausea, acute cognitive dysfunction, or other, and noted on the first 3 days of PT.
Results: PT was started median postoperative Day1. Only 5 patients were independent in BAMS activity 2: transfer from bed to wheelchair, on PT Day1. Primary limiting factors for the 55 patients not independent were fatigue (44%) and fear of being mobilized (33%). 36 patients completed the planned PT on Day1, with the primary limiting factors for non-compliers being fatigue (38%) and pain in the residual limb (24%).
Interpretation / Conclusion: Fatigue and fear of being mobilized were the most frequent limiting factors for independent mobilization out of bed after LEA. Correspondingly, fatigue and pain in the residual limb restricted participation in the planned PT. These findings can be utilized in a multimodal perioperative setting to optimize treatment for overcoming these barriers, potentially leading to better compliance and outcomes.
Rehne Lessmann Hansen1, Per Hviid Gundtoft1, Juozas Petruskevicius1, Ole Juul1,2, Klaus Kjær Petersen1, Christen Ravn1,2
1. Traume og infektionssektoren, Ortopædkirurgisk Afdeling, Aarhus Universitetshospital 2. Forsvarets Sanitetskommando
Background: Due to the war in Ukraine the number of casualties and complex cases exceeds the Ukrainian health service capacity. In collaboration with Health authorities of EU’s countries many injured patients were transferred for further treatment in western countries, including Denmark.
Aim: To report experience from treating war-related musculoskeletal injuries at Aarhus University Hospital (AUH).
Materials and Methods: All casualties referred to AUH due to traumatic injuries suffered in Ukraine in 2022 were prospectively included in this cohort study focusing on injuries, treatment delay, microbiology, treatment, mental status, rehabilitation, and discharge.
Results: A total of 12 patients (male, 9-50 years) were transferred to AUH with a mean delay of 66 (4-157) days after injury. Only one patient arrived at daytime. Eight patients arrived without relatives, and nine patients were only able to speak Ukrainian or Russian. On arrival to AUH, patients were isolated, assessed and trauma scanned. Most injuries involved the extremities (10 cases), but injuries also involved spine (1), thorax (1), abdomen (2) and the brain (4). Nine patients had multiple injuries. Open wounds and colonization with CPO were seen in nine patients. Two patients arrived in sepsis and one with COVID. Treatment measures were organised with multidisciplinary approach. Total 35 operations were performed in the orthopaedic (24 procedures), abdominal (8) and neurosurgical (3) departments. Mean hospital stay was 33 days and indications for prolonged admission includes multiple operations, chronic infections, complications, malnutrition, and specialized physical and psychological rehabilitation. None of the patients were amputated, and only three patients were discharged in wheelchair. Three pts were discharged back to Ukraine, whereas the rest were either rehabilitated at local hospitals or in a municipal setting.
Interpretation / Conclusion: Several patients had a complex fracture-related infections that most likely could have been avoided if the patients were referred directly to Denmark after primary stabilization in Ukraine. We suggest sharing the efforts and experience in a few multidisciplinary centres where patients could also benefit from each other’s company.
1. Traume og infektionssektoren, Ortopædkirurgisk Afdeling, Aarhus Universitetshospital 2. Forsvarets Sanitetskommando
Background: Due to the war in Ukraine the number of casualties and complex cases exceeds the Ukrainian health service capacity. In collaboration with Health authorities of EU’s countries many injured patients were transferred for further treatment in western countries, including Denmark.
Aim: To report experience from treating war-related musculoskeletal injuries at Aarhus University Hospital (AUH).
Materials and Methods: All casualties referred to AUH due to traumatic injuries suffered in Ukraine in 2022 were prospectively included in this cohort study focusing on injuries, treatment delay, microbiology, treatment, mental status, rehabilitation, and discharge.
Results: A total of 12 patients (male, 9-50 years) were transferred to AUH with a mean delay of 66 (4-157) days after injury. Only one patient arrived at daytime. Eight patients arrived without relatives, and nine patients were only able to speak Ukrainian or Russian. On arrival to AUH, patients were isolated, assessed and trauma scanned. Most injuries involved the extremities (10 cases), but injuries also involved spine (1), thorax (1), abdomen (2) and the brain (4). Nine patients had multiple injuries. Open wounds and colonization with CPO were seen in nine patients. Two patients arrived in sepsis and one with COVID. Treatment measures were organised with multidisciplinary approach. Total 35 operations were performed in the orthopaedic (24 procedures), abdominal (8) and neurosurgical (3) departments. Mean hospital stay was 33 days and indications for prolonged admission includes multiple operations, chronic infections, complications, malnutrition, and specialized physical and psychological rehabilitation. None of the patients were amputated, and only three patients were discharged in wheelchair. Three pts were discharged back to Ukraine, whereas the rest were either rehabilitated at local hospitals or in a municipal setting.
Interpretation / Conclusion: Several patients had a complex fracture-related infections that most likely could have been avoided if the patients were referred directly to Denmark after primary stabilization in Ukraine. We suggest sharing the efforts and experience in a few multidisciplinary centres where patients could also benefit from each other’s company.
Anna Trier Heiberg Brix1,2, Katrine Hass Rubin2,3, Tine Nymark1,2, Hagen Schmal1,4, Martin Lindberg-Larsen1,2
1. Department of Orthopedic Surgery and Traumatology, Odense University Hospital 2. Department of Clinical Research, University of Southern Denmark 3. OPEN - Open Patient Data Explorative Network, Odense University Hospital and University of Southern Denmark 4. Department of Orthopedics and Traumatology, University Medical Center Freiburg
Background: Major lower extremity amputations (MLEA), defined as amputation above the ankle, are common procedures. Potential changes in surgical strategy and patient characteristics over time have not been described previously.
Aim: The aim of this study was to describe the incidence rates and surgical strategies of first-time MLEAs from 2010 to 2021. Furthermore, to describe patient and surgical center demographics during the same period.
Materials and Methods: This is an observational nationwide register study including all first-time MLEAs performed in patients =18 years from 2010 to 2021. Data were achieved from the Danish National Patient Register and the Danish National Prescription Database.
Results: A total of 12.669 first-time MLEA patients were identified in the study period. The annual number of first-time MLEAs each year was unchanged at approx. 1000 annually during the study period. In 2021 the total incidence was 21.3/100.000 and the adjusted incidence decreased by 2.3% (95% CI 1.8-2.8) per year. The frequency of transfemoral amputations increased, whereas knee disarticulation and transtibial amputation decreased. The comorbidity burden and age at MLEA were also unchanged during the study period. Within the study period a total 20% of patients underwent minor amputation, defined as below or through the ankle, and a total 39% had revascularization surgery prior to MLEA. There was no change in annual rates throughout the study period. The surgical centers performing MLEA were reduced from 26 to 17 during the study period.
Interpretation / Conclusion: We observed a decreasing incidence of first-time MLEA in Denmark and a shift towards increased use of transfemoral amputations. This trend was not explained by higher age, increasing comorbidity burden, or previous surgeries before first-time MLEA, as these factors were constant. Whether the change in surgical strategy is to the benefit of the patients should be investigated further.
1. Department of Orthopedic Surgery and Traumatology, Odense University Hospital 2. Department of Clinical Research, University of Southern Denmark 3. OPEN - Open Patient Data Explorative Network, Odense University Hospital and University of Southern Denmark 4. Department of Orthopedics and Traumatology, University Medical Center Freiburg
Background: Major lower extremity amputations (MLEA), defined as amputation above the ankle, are common procedures. Potential changes in surgical strategy and patient characteristics over time have not been described previously.
Aim: The aim of this study was to describe the incidence rates and surgical strategies of first-time MLEAs from 2010 to 2021. Furthermore, to describe patient and surgical center demographics during the same period.
Materials and Methods: This is an observational nationwide register study including all first-time MLEAs performed in patients =18 years from 2010 to 2021. Data were achieved from the Danish National Patient Register and the Danish National Prescription Database.
Results: A total of 12.669 first-time MLEA patients were identified in the study period. The annual number of first-time MLEAs each year was unchanged at approx. 1000 annually during the study period. In 2021 the total incidence was 21.3/100.000 and the adjusted incidence decreased by 2.3% (95% CI 1.8-2.8) per year. The frequency of transfemoral amputations increased, whereas knee disarticulation and transtibial amputation decreased. The comorbidity burden and age at MLEA were also unchanged during the study period. Within the study period a total 20% of patients underwent minor amputation, defined as below or through the ankle, and a total 39% had revascularization surgery prior to MLEA. There was no change in annual rates throughout the study period. The surgical centers performing MLEA were reduced from 26 to 17 during the study period.
Interpretation / Conclusion: We observed a decreasing incidence of first-time MLEA in Denmark and a shift towards increased use of transfemoral amputations. This trend was not explained by higher age, increasing comorbidity burden, or previous surgeries before first-time MLEA, as these factors were constant. Whether the change in surgical strategy is to the benefit of the patients should be investigated further.
Andrea Thorn1, Bodil Engelmann2, Ninna Pedersen3, Thomas Baad-Hansen4, Michael Mørk Petersen1
1 . Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen; 2. Department of Oncology, Herlev Hospital; 3. Department of Oncology, Aarhus Universitetshospital; 4. Department of Orthopaedic Surgery, Aarhus Universitetshospital.
Background: Treatment of Soft tissue sarcomas (STS) is in Denmark only practiced in two sarcoma centers: Aarhus University Hospital (AUH) and Rigshospitalet/Herlev Hospital (RH/HH). In 2018 the Danish Sarcoma Group approved a new cancer guideline dealing with radiotherapy of localized STS, and it was concluded that radiotherapy combined with limb sparing surgery with wide or marginal margin is the treatment of choice for all localized deep-seated H-M STS. The new guidelines are very similar to what has been the clinical practice in AUH for many years while the Sarcoma Center at RH/HH until 2018 has had a different more individualized approach not always treating with radiation therapy if tumors were removed with a wide margin regardless of tumor size.
Aim: Evaluate the treatment of deep-seated high-grade STS by comparing two different regimes of postoperative radiotherapy treatment regarding local recurrence (LR) and overall survival (OS).
Materials and Methods: We included the patients from the Danish Sarcoma Registry, with newly diagnosed H-M STS (Trojani 2+3) of the extremities or trunk wall between Jan 1, 2000 and Dec 31, 2016, primary surgery for a deep-seated (sub-fascial) tumor, and age > 18 with. The cohort was specifically validated regarding LR and OS. Statistics: Kaplan Meier survival analysis and log-rank test for comparison of groups.
Results: A total of 732 patients (RH/HH: n=337, AUH: n=395) with localized deep-seated H-M STS in the extremities and trunk wall, were operated on between 2000 and 2016. The last follow-up was on 01/01/2023 giving a minimum follow-up of 6 years. 432 patients died during the follow-up (RH/HH: n=201, AUH: n=231). The 5-year OS for RH/HH was 55.8% (CI-95: 50.5-61.1) and 54,4% (CI-95: 49.5-59.3) and no significant difference could be found (p=1). The same result could be found when looking at LR. 253 patients (RH/HH: n=117), AUH: n=136) were diagnosed with LR after their primary operation. The 5-year local recurrence free survival for RH/HH was 68% (CI- 95 63-72-9) and 67.8% (CI-95 63.2-72.5) for AUH and no difference could be found between the centers (p=1).
Interpretation / Conclusion: There was no statistically significant difference in OS or LR rates between patients treated at RH/HH and AUH.
1 . Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen; 2. Department of Oncology, Herlev Hospital; 3. Department of Oncology, Aarhus Universitetshospital; 4. Department of Orthopaedic Surgery, Aarhus Universitetshospital.
Background: Treatment of Soft tissue sarcomas (STS) is in Denmark only practiced in two sarcoma centers: Aarhus University Hospital (AUH) and Rigshospitalet/Herlev Hospital (RH/HH). In 2018 the Danish Sarcoma Group approved a new cancer guideline dealing with radiotherapy of localized STS, and it was concluded that radiotherapy combined with limb sparing surgery with wide or marginal margin is the treatment of choice for all localized deep-seated H-M STS. The new guidelines are very similar to what has been the clinical practice in AUH for many years while the Sarcoma Center at RH/HH until 2018 has had a different more individualized approach not always treating with radiation therapy if tumors were removed with a wide margin regardless of tumor size.
Aim: Evaluate the treatment of deep-seated high-grade STS by comparing two different regimes of postoperative radiotherapy treatment regarding local recurrence (LR) and overall survival (OS).
Materials and Methods: We included the patients from the Danish Sarcoma Registry, with newly diagnosed H-M STS (Trojani 2+3) of the extremities or trunk wall between Jan 1, 2000 and Dec 31, 2016, primary surgery for a deep-seated (sub-fascial) tumor, and age > 18 with. The cohort was specifically validated regarding LR and OS. Statistics: Kaplan Meier survival analysis and log-rank test for comparison of groups.
Results: A total of 732 patients (RH/HH: n=337, AUH: n=395) with localized deep-seated H-M STS in the extremities and trunk wall, were operated on between 2000 and 2016. The last follow-up was on 01/01/2023 giving a minimum follow-up of 6 years. 432 patients died during the follow-up (RH/HH: n=201, AUH: n=231). The 5-year OS for RH/HH was 55.8% (CI-95: 50.5-61.1) and 54,4% (CI-95: 49.5-59.3) and no significant difference could be found (p=1). The same result could be found when looking at LR. 253 patients (RH/HH: n=117), AUH: n=136) were diagnosed with LR after their primary operation. The 5-year local recurrence free survival for RH/HH was 68% (CI- 95 63-72-9) and 67.8% (CI-95 63.2-72.5) for AUH and no difference could be found between the centers (p=1).
Interpretation / Conclusion: There was no statistically significant difference in OS or LR rates between patients treated at RH/HH and AUH.
Thea Hovgaard Ladegaard1, Michala Skovlund Sørensen1, Michael Mørk Petersen1, Jakob Stensballe2,3
1. Musculoskeletal Tumor section, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen 2. Department of Anaesthesiology and Trauma Centre, Rigshospitalet, Copenhagen University Hospital, Denmark 3. Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Denmark
Background: Patients with bone metastases in the femur (BMf) experience pathological fractures requiring surgery with cemented endoprostheses (cEPR). At the cementation process and prosthesis insertion, patients are at risk of experiencing hypoxia, hypotension, cardiac failure and potentially cardiac arrest, known as bone cement implantation syndrome (BCIS).
Aim: To investigate the incidence of BCIS in patients surgically treated with cEPR due to BMf.
Materials and Methods: We retrospectively assessed all patients with BMf operated with cEPR in two 18 months periods 2017 – 2018 (early cohort) and 2019 – 2020 (late cohort). Data were obtained from medical records. BCIS was classified 1-3 by degree of hypotension, desaturation and occurrence of pulmonary embolia, cardiac failure and/or death in the period from cementation until 5 minutes after. Patients with unknown time of cementation were excluded (n=22). Fishers exact test compared groups.
Results: We identified 165 patients, (79 in the early and 86 in the late cohort). In total 56/165 (34%) experienced BCIS (33% in the early cohort vs 35% in the late cohort). The classification of BCIS severity was: grade 1 (11% vs 21%), grade 2 (18% vs 14%) and grade 3 (3.8% vs 0%) in the early and late cohort, respectively. A trend toward an increase in mild BCIS (grade 1) and a decrease in severe BCIS (grade 2+3) were seen between the early and late cohort (p=0.068). The use of vasopressors increased significantly from 59% to 86% between the two periods (p<0.001).
Interpretation / Conclusion: BCIS is occurring in more than 1/3 of patients operated on for BMf with cEPR. Our study showed a reduction in the severity of BCIS and highlights the continued need to prevent BCIS in patients with BMf.
1. Musculoskeletal Tumor section, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen 2. Department of Anaesthesiology and Trauma Centre, Rigshospitalet, Copenhagen University Hospital, Denmark 3. Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Denmark
Background: Patients with bone metastases in the femur (BMf) experience pathological fractures requiring surgery with cemented endoprostheses (cEPR). At the cementation process and prosthesis insertion, patients are at risk of experiencing hypoxia, hypotension, cardiac failure and potentially cardiac arrest, known as bone cement implantation syndrome (BCIS).
Aim: To investigate the incidence of BCIS in patients surgically treated with cEPR due to BMf.
Materials and Methods: We retrospectively assessed all patients with BMf operated with cEPR in two 18 months periods 2017 – 2018 (early cohort) and 2019 – 2020 (late cohort). Data were obtained from medical records. BCIS was classified 1-3 by degree of hypotension, desaturation and occurrence of pulmonary embolia, cardiac failure and/or death in the period from cementation until 5 minutes after. Patients with unknown time of cementation were excluded (n=22). Fishers exact test compared groups.
Results: We identified 165 patients, (79 in the early and 86 in the late cohort). In total 56/165 (34%) experienced BCIS (33% in the early cohort vs 35% in the late cohort). The classification of BCIS severity was: grade 1 (11% vs 21%), grade 2 (18% vs 14%) and grade 3 (3.8% vs 0%) in the early and late cohort, respectively. A trend toward an increase in mild BCIS (grade 1) and a decrease in severe BCIS (grade 2+3) were seen between the early and late cohort (p=0.068). The use of vasopressors increased significantly from 59% to 86% between the two periods (p<0.001).
Interpretation / Conclusion: BCIS is occurring in more than 1/3 of patients operated on for BMf with cEPR. Our study showed a reduction in the severity of BCIS and highlights the continued need to prevent BCIS in patients with BMf.
Christina Holm1,2, Andrea Thorn1, Thomas Baad-Hansen2, Michael Mørk Petersen1
1The Musculoskeletal Tumor Section, The Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Denmark, 2Department of Orthopedic Surgery, Tumor Section, Aarhus University Hospital, Aarhus, Denmark
Background: Angiosarcoma is a rare tissue sarcoma, representing approximately 1-2% of all soft tissue sarcomas. Angiosarcomas origins from endothelial cells hence classified as a vascular neoplasm. Angiosarcomas arise at any anatomic site with the vast majority being located at cutaneous sites, primarily head/neck, in particular the scalp. Angiosarcoma is a understudied cancer with a suggested increasing incidence and high mortality.
Aim: The purpose with present study was to make a long-term population-based evaluation of overall survival, risk of local recurrence and metastasis in patients with newly diagnosed angiosarcomas in the extremities and trunk wall.
Materials and Methods: We identified a retrospective population-based consecutive cohort with newly diagnosed angiosarcoma in the extremities or trunk wall. Patients were included from The Danish Sarcoma Registry from January 1st, 2000 and December 31, 2016. Kaplan-Meier survival analysis was used for evaluation of overall patient survival. Competing risk analysis was used for assessing cumulative incidence of recurrence and metastasis. Patients were followed until death or end of study (January 1, 2023) resulting in a minimum follow-up of 6 years.
Results: We included n=72 patients with a mean age of 66 (22-95) years (F/M=38/34). Fifteen patients (21%) were alive at the end of study. Overall survival was 33% (95%CI: 22%-44%) and 26% (95%CI: 16%-36%) after 5, 10 years respectively. We found no differences in overall survival between patients + local recurrence or + metastasis (p=0.8), (p=0.2) respectively. The cumulative incidence of local recurrence was 32% (95%CI: 21%-43%) and 33% (95%CI: 22%-44%) at 5 and 10 years respectively. The cumulative incidence of metastasis was 13% (95%CI: 5%-21%) and 14% (95%CI: 6%-23%) after 5 and 10 year respectively.
Interpretation / Conclusion: Our long-term results from a population-based cohort demonstrated that angiosarcoma is an aggressive subtype of soft tissue sarcomas with high risk of local recurrence and metastasizing. The long-term overall prognosis is poor despite aggressive treatment.
1The Musculoskeletal Tumor Section, The Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Denmark, 2Department of Orthopedic Surgery, Tumor Section, Aarhus University Hospital, Aarhus, Denmark
Background: Angiosarcoma is a rare tissue sarcoma, representing approximately 1-2% of all soft tissue sarcomas. Angiosarcomas origins from endothelial cells hence classified as a vascular neoplasm. Angiosarcomas arise at any anatomic site with the vast majority being located at cutaneous sites, primarily head/neck, in particular the scalp. Angiosarcoma is a understudied cancer with a suggested increasing incidence and high mortality.
Aim: The purpose with present study was to make a long-term population-based evaluation of overall survival, risk of local recurrence and metastasis in patients with newly diagnosed angiosarcomas in the extremities and trunk wall.
Materials and Methods: We identified a retrospective population-based consecutive cohort with newly diagnosed angiosarcoma in the extremities or trunk wall. Patients were included from The Danish Sarcoma Registry from January 1st, 2000 and December 31, 2016. Kaplan-Meier survival analysis was used for evaluation of overall patient survival. Competing risk analysis was used for assessing cumulative incidence of recurrence and metastasis. Patients were followed until death or end of study (January 1, 2023) resulting in a minimum follow-up of 6 years.
Results: We included n=72 patients with a mean age of 66 (22-95) years (F/M=38/34). Fifteen patients (21%) were alive at the end of study. Overall survival was 33% (95%CI: 22%-44%) and 26% (95%CI: 16%-36%) after 5, 10 years respectively. We found no differences in overall survival between patients + local recurrence or + metastasis (p=0.8), (p=0.2) respectively. The cumulative incidence of local recurrence was 32% (95%CI: 21%-43%) and 33% (95%CI: 22%-44%) at 5 and 10 years respectively. The cumulative incidence of metastasis was 13% (95%CI: 5%-21%) and 14% (95%CI: 6%-23%) after 5 and 10 year respectively.
Interpretation / Conclusion: Our long-term results from a population-based cohort demonstrated that angiosarcoma is an aggressive subtype of soft tissue sarcomas with high risk of local recurrence and metastasizing. The long-term overall prognosis is poor despite aggressive treatment.
Thea Hovgaard Ladegaard1, Michael Mørk Petersen1, Michala Skovlund Sørensen1
1. Musculoskeletal Tumor Section, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen
Background: Surgical treatment of metastatic bone disease in the extremities (BMex) is a tradeoff between preserving limb function without posing a risk for survival. A previous study (Sørensen et al., Medicine 2016) fount that extended surgery is not a risk for 30-day mortality and hypothesized that wide resection and reconstruction might reduce the risk of postoperative mortality.
Aim: To validate that the extent of the surgical trauma does not increase the risk of 30-day mortality in patients having surgery with endoprostheses (EPR) or internal fixation (IF) for BMex and identify if IF increases the risk of 30-day mortality.
Materials and Methods: A retrospective cohort study on a population-based cohort having EPR or IF for BMex in the Capital Region of Denmark Jan 2014-Dec 2019. Intraoperative variables and patient demographics were evaluated for association with 30-day mortality by logistic regression analysis and Kaplan Meier evaluated survival. We had no loss to follow-up.
Results: We identified 437 patients having surgical treatment for BMex. Overall 30-days survival was 85% (95CI: 81-88). Univariate analysis identified ASA score 3+4 (OR 3.50 [95CI: 1.68-7.3]), Karnofsky <70 (OR 5.84 [95CI: 3.33-10.93]), fast growth cancer (OR 3.97 [95CI: 2.3-6.86]), visceral metastases (OR 2.86 [95CI: 1.55-5.28]), multiple bone metastases (OR 2.38 [95CI: 1.10- 5.19]) and treatment at a secondary surgical center (OR 1.88 [95CI: 1.11-3.18]) as risk factors for 30-day mortality. Only male gender (OR 2.51 [95CI: 1.19-5.30]), ASA 3+4 (OR 3.2 [95%CI: 1.12-9.16]), Karnofsky <70 (OR 4.01 [95CI: 1.95- 8.23]), fast growth cancer (OR 3.5 [95CI: 1.62- 7.52]) and multiple bone metastases (OR 3.38 [95CI: 1.13-10.10]) were independent prognostic factors for 30-day mortality in multivariate analysis. No parameters describing the extent of the surgical trauma were found to be associated with 30-day mortality.
Interpretation / Conclusion: We confirmed our hypotheses about extent of surgery, measured as blood loss, duration of surgery and degree of bone resection, not being associated with 30-day mortality. Further, we did not find IF as a risk factor. Instead general health status of the patient and extent of primary cancer disease influenced survival post surgery.
1. Musculoskeletal Tumor Section, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen
Background: Surgical treatment of metastatic bone disease in the extremities (BMex) is a tradeoff between preserving limb function without posing a risk for survival. A previous study (Sørensen et al., Medicine 2016) fount that extended surgery is not a risk for 30-day mortality and hypothesized that wide resection and reconstruction might reduce the risk of postoperative mortality.
Aim: To validate that the extent of the surgical trauma does not increase the risk of 30-day mortality in patients having surgery with endoprostheses (EPR) or internal fixation (IF) for BMex and identify if IF increases the risk of 30-day mortality.
Materials and Methods: A retrospective cohort study on a population-based cohort having EPR or IF for BMex in the Capital Region of Denmark Jan 2014-Dec 2019. Intraoperative variables and patient demographics were evaluated for association with 30-day mortality by logistic regression analysis and Kaplan Meier evaluated survival. We had no loss to follow-up.
Results: We identified 437 patients having surgical treatment for BMex. Overall 30-days survival was 85% (95CI: 81-88). Univariate analysis identified ASA score 3+4 (OR 3.50 [95CI: 1.68-7.3]), Karnofsky <70 (OR 5.84 [95CI: 3.33-10.93]), fast growth cancer (OR 3.97 [95CI: 2.3-6.86]), visceral metastases (OR 2.86 [95CI: 1.55-5.28]), multiple bone metastases (OR 2.38 [95CI: 1.10- 5.19]) and treatment at a secondary surgical center (OR 1.88 [95CI: 1.11-3.18]) as risk factors for 30-day mortality. Only male gender (OR 2.51 [95CI: 1.19-5.30]), ASA 3+4 (OR 3.2 [95%CI: 1.12-9.16]), Karnofsky <70 (OR 4.01 [95CI: 1.95- 8.23]), fast growth cancer (OR 3.5 [95CI: 1.62- 7.52]) and multiple bone metastases (OR 3.38 [95CI: 1.13-10.10]) were independent prognostic factors for 30-day mortality in multivariate analysis. No parameters describing the extent of the surgical trauma were found to be associated with 30-day mortality.
Interpretation / Conclusion: We confirmed our hypotheses about extent of surgery, measured as blood loss, duration of surgery and degree of bone resection, not being associated with 30-day mortality. Further, we did not find IF as a risk factor. Instead general health status of the patient and extent of primary cancer disease influenced survival post surgery.