Session 18: Foot/ankle
15. November
12:45 - 13:45
Lokale: Skovbrynet
Chair: Louise Lau Simonsen & Kristian Behrndtz
142. "Wide Awake Local Anesthetic No Tourniquet" used in forefoot surgery: Patient-reported pain and anxiety during administration, surgery and post-surgery.
Ane Linde1, Niels Frederik Breum Jakobsen1, Torben Bæk Hansen1,2
1. University Clinic for Hand, Hip and Knee Surgery. Department of Orthopedics, Regional
Hospital Gødstrup
2. Department of Clinical Medicine, Aarhus University
Background: Wide Awake Local Anesthetic No Tourniquet
(WALANT) is used as a local anesthetic procedure
in hand surgery with high satisfaction rates and is
now considered as a safe and effective surgeon-
based anesthesia. The procedure is less invasive
than regional block or general anesthesia (GA) and
there is no need for a tourniquet, reducing
postoperative pain, hospital stay and economical
costs.
Aim: As most publications have been based on hand
surgical procedures, the aim of this study was to test
the feasibility of WALANT as an anesthetic
procedure during forefoot surgery.
Materials and Methods: Ten patients scheduled for cheilectomy of the
first metatarso-phalangeal joint were enrolled
into this pilot study. All had normal sensation and
palpable foot pulses.
WALANT is a mixture of lidocain with adrenalin,
bicarbonate, NaCl, and ropivacain. 35-40ml was
administrated to the forefoot as a combination of
a nerve block to the first ray and infiltration of the
incision site.
The patients rated their highest perceived pain
and anxiety on a Numeric Rating Scale (NRS 0-
10) during administration of WALANT, during
surgery and one hour post-surgery.
For comparison, five patients scheduled for
forefoot surgery in regional Saphenous block,
rated their highest perceived pain and anxiety
during administration.
Results: The mean (range) NRS pain-score was 3,2 (1-7)
during administration, 0,3 (0-1) during surgery and
0,1 (0-1) post-surgery. The mean anxiety-score was
0,8 (0-5) during administration, 1,0 (0-5) during
surgery and 0 post-surgery.
None of the patients were converted to GA or
required additional local anesthesia. There was no
need to apply a tourniquet.
The five regional block patients had a mean (range)
pain-score of 5,6 (4-8) and mean anxiety-score of
2,0 (0-8)during administration.
Interpretation / Conclusion: This pilot study suggests that WALANT is a reliable
anesthesia, well tolerated in cheilectomies, with low
patient-reported pain and anxiety. Further studies
may expand its suitability in other forefoot surgeries,
like hallux valgus surgery.
143. Feasibility of rehabiliation following total ankle arthroplasty
Louise Mortensen1, Gustav Færch Ussing1, Kristian Henrik Brink Behrndtz2, Nanna Rolving1,
1, Department of Physiotherapy and Occupational Therapy, Aarhus University
Hospital, Denmark
2, Department of Orthopedic Surgery, Aarhus University Hospital, Denmark
Background: Ankle injuries increases the risk of ankle joint
arthritis (AJA), and 70-90% of AJA is post-
traumatic. One treatment of AJA is total ankle
arthroplasty (TAA), preserving some range of
motion in the ankle. The use of TAA has risen,
but postoperative treatment and rehabilitation
varies nationally and internationally.
Aim: Evaluate stepwise TAA rehabilitation program
and explore the patients' self-reported physical
function, symptoms and objectively measured
functional capacity three and six months after
TAA.
Materials and Methods: A single-group feasibility study at Aarhus
University Hospital with AJA patients
undergoing TAA. Rehabilitation started six
weeks post-surgery, lasting 18 weeks.
Patients' satisfaction was evaluated with two
anchor questions, scored on a 5-point Likert
Scale. Compliance and pain responses were
evaluated through an exercise diary.
Furthermore, patients answered three patient-
reported questionnaires; The European Foot
and Ankle Society(EFAS), the American
Orthopedic Foot and Ankle Society(AOFAS)
and the Visual Analog Scale(VAS) and went
through the functional tests; 30-second sit to
stand, 2 minute-walking test and 11 step stair
test before surgery(baseline), three and six
months post-surgery.
Results: 17 of 18 patients participated, 15 completed the
rehabilitation program and follow-up. Preliminary
analysis of 13 patients show high satisfaction
and compliance with no adverse events related
to the rehabilitation. The EFAS score improved
from (mean (SD)) 15.9 (4.8) to 25.1 (6.9) from
baseline to three months' follow-up, the AOFAS
improved from 56.3 (16.3) to 72.3 (14.3), VAS
decreased from 67.6 (21.0) to 33.9 (22.8), and
patients continued to improve at six months. All
functional outcome measures improved from
baseline to three months' follow-up, except 2-
minute walking test, but at six months' follow-up
all tests had improved.
Interpretation / Conclusion: A two phase stepwise rehabilitation program is feasible in patients with a TAA. Early results ( < one year) of patient-reported outcomes and functional capacity after TAA have not been reported before. These results show that patients with a TAA can expect great improvements 6 months after surgery.
144. Time trends in incidence and treatment of ankle fractures in Denmark from 1997 to 2018: A national population-based cohort study
Per Gundtoft1, Alma Becic Pedersen2,3, Bjarke Viberg4, 5
1: Orthopedic Department, Aarhus University Hospital
2: Department of Clinical Epidemiology, Aarhus University Hospital
3: Department of Clinical Medicin, Aarhus University
4: Department of Orthopaedic Surgery and Traumatology, Odense University
Hospital
5: Department of Clinical Research, University of Southern Denmark
Background: Previous studies showed large variation in the
incidence of ankle fractures as they are often
based on single center or regional data alone.
A nationwide data are necessary to gain
knowledge of the current trends and burden on
the health care system.
Aim: To assess the incidence of ankle fractures in
Denmark, overall and by age and sex during
1997-2018.
Materials and Methods: Ankle fractures in patients >18 years old
were identified in the Danish National Patient
Register using the diagnosis codes S82.5,
S82.6, S82.7A, S82.7B, S82.8B, and
S82.8D. Surgical treatment of ankle fracture
was identified using surgical procedure
codes for plate (KNHJ6*), screws alone
(KNHJ7*), nail (KNHJ5*), wire, rod, cerclage
or pin (KNHJ4*), external fixation (KNHJ2*)
and other. The positive predictive value of
the ankle fracture diagnosis code is 0.89 and
for surgical procedure code it is 0.82.
Incidence rates per 100,000 and Incidence
Rate Ratio (IRR) are reported with 95%
confidence interval.
Results: We identified 155,740 ankle fractures, with
the lateral malleolus fractures as most
common (71%).
The overall mean incidence rate during
1997-2018 was 164 [163; 165] per 100,000,
154 [152; 155] for men and 203 [202; 205]
for women.
The incidence rate increased from 155 [131;
179] during 1997-2006 to 173 [147; 199]
during 2007-2018, corresponding to an IRR
of 1.12 [1.10; 1.12].
Thiis increase was primarily driven by the
incidence increase for women, with an IRR
of 1.21 [1.20; 1.23] and for patients above
50, with an IRR of 1.22 [1.08-1.10).
The proportion of patients surgically treated
increased from 21% in 1997-2006 to 25% in
2007-2018, and most common surgical
treatment used were plates.
Interpretation / Conclusion: The incidence of ankle fracture increased over
the study period. The increasing incidence was
primarily due to an increased incidence in
women and in the elder population. Therefore,
a greater burden to the health care system can
be expected in the future, especially as more
patients are treated surgically in the later years.
145. The challenges of physical activity in the presence of a diabetic foot ulcer; a search for evidence-based guidance
Birgit Rasmussen1,2, Lisbeth Uhrenfeldt1,2
1. Department of Orthopaedic Surgery, Lillebaelt Hospital, Kolding
2. Department of Regional Health Research, Southern Danish University;
Background: For patients with a diabetic foot ulcer (DFU)
off-loading regimens are key to promoting
healing. Inactivity as a direct consequence of
the treatment is a challenge for the health and
well-being of all, however, especially for
diabetic patients. With treatment lasting for
months and even years, loss of physical
capacity and functioning and individual
suffering can be the result. With appropriate
off-loading some physical activity seems to be
acceptable; however the positive outcome
from physical activity in the presence of a
DFU received little attention in research.
Aim: The aim is to explore the derived positive
meaning of physical activity in patients with
imposed mobility restrictions due to a DFU and
to offer new evidence-based guidelines for
patient treatment.
Materials and Methods: Based on the Joanna Briggs Institute guiding
framework, we conducted two comprehensive,
systematic reviews. Search terms were related
to 1) patients with DFU being imposed limitations
on their mobility and 2) changes in physical
activity, wound size, physical fitness and
functioning, and experiences of well-being. We
searched MEDLINE, Embase, and CINAHL for
all types of studies.
Results: After screening of 2886 studies, 11 studies were
included. Screening of reference lists yielded two
additional studies. Of the 13 included studies, 11
were quantitative, one was qualitative, and one
was a case report study. A major focus is on
training and healing of the wound. In that
context, training is safe, and muscle function
seems to improve. Patients’ own and preferred
physical activity and their well-being in daily life
are poorly understood. Five systematic reviews
gave rise to the construct of an umbrella review,
the highest level of evidence to guide practice,
concerning how and why physical activity
interventions work and how they are experienced
by the patients.
Interpretation / Conclusion: Findings from the study raised knowledge gaps.
Training is a possibility and can support the
healing of DFU. However, research is still lacking
that provides evidence for giving patients
evidence-based restrictions in, or specific
directions for their choices of physical activity
adding well-being to their daily life.
146. Wound complications and risk factors following calcaneal fracture surgery using sinus tarsi approach - A multicenter study
Bjarke Viberg1, Louis Domino Borbye1, Morten Schultz Larsen1, Upender Martin Singh2, Marianne Lind2, Jeannette Østergaard Penny3, Lauritz Walsøe4, Per Hviid Gundtoft4
1. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital;
2. Department of Orthopaedic Surgery and Traumatology, Righospitalet;
3. Department of Orthopaedic Surgery and Traumatology, Zealand University Hospital;
4. Department of Orthopaedic Surgery and Traumatology, Aarhus University Hospital.
Background: Surgical treatment calcaneal fractures (CF) are often
associated with a high complication rate but the
relatively new Sinus Tarsi Approach (STA) have
lower risk of complications. However, even though
the STA have a lower risk of complications, wound
complications are still a concern.
Aim: The aim was to assess risk factors for wound
complication after surgical treatment of CF with STA
or similar minimal invasive approach.
Materials and Methods: This multicenter retrospective study identified
patients through the administrative databases of four
hospitals (Aarhus, Køge, Odense, Rigshospitalet)
treating CF in the period of July 2018-June 2022
with one-year of follow up using the diagnosis code
S920. The electronic medical records of all identified
patients were reviewed for relevant data including
wound complications and CT-scans were assessed
by experienced traumatologists. Patient with ELA
(n=10), tongue-type fracture (n=13) and missing
data on wound assessment (n=2) were excluded.
Results: The final cohort consisted of 148 CF (143
patients), median age was 50 (range 11-78),
72% were male, and 36% had good health (ASA
group 1). Of the 148 CF, 13 (9%) had
postoperative wound complications, however 12
were treated non-operatively (4 without
antibiotics) and 1 was treated operatively for
deep infection.
There following factors were associated with a
higher risk for wound complications: open
fracture (p=0.032), psychiatric disorder
(p=0.012), and other injuries (p=0.021). There
was a tendency for more severe fractures
(p=0.063), type of implant (p=0.054), and heart
disease (p=0.079). Non-significant risk factors
were age, sex, ASA score, cohabitation,
smoking, alcohol, substance abuse, diabetes,
dementia, trauma mechanism, and time to
surgery.
Interpretation / Conclusion: There were 9% with postoperative wound
complications but only 6% needed antibiotics or
surgery. There were a higher proportion in patients
with open fractures and patients with psychiatric
disease or had sustained other injury. A
differentiated, preventive wound care regime based
on patient and fracture characteristics might benefit
patients with CF in the future.
147. Pathologies in Children’s Feet. A cross-sectional evaluation of foot pathologies across age.
Søren Bødtker1, Camilla Hedegaard Larsen2, Andreas Balslev-Clausen3, Lisa Bomark4, Christian Wong5
1;2; 3; 5; Dep. Orthopedic Surgery, University Hospital Rigshospitalet
4; The Association of Danish Podiatrists. Denmark
Background: Caregivers often seek medical assistance when
their child experiences podiatric ailments.
Podiatric diseases such as ingrown toenails,
callosities, warts, metatarsus varus and hallux
valgus frequently occur in children and
adolescents. However, treatment, prevention and
rehabilitation are often based on empirical
experiences, thus as a first endeavour clinical,
epidemiological mapping of podiatric diseases in
children’s feet is warranted. In this study, we set
out to describe the prevalence of foot
pathologies among Danish school children at
different ages.
Aim: We want to describe the physiological conditions
and the occurrence of foot diseases among Danish
schoolchildren of different ages.
Materials and Methods: In this cross-sectional study, we evaluated children’s
feet for podiatric diseases. The clinical status of the
feet was examined by teams consisting of two
podiatrists each. Specifically, we evaluated
deformities of the foot, foot pathologies and their
anatomical localization
Results: We evaluated 501 children (1002 extremities). Four
hundred and seventeen children had one or more of
the investigated foot deformities or pathologies. We
found a total of 266 various foot pathologies among
the Danish schoolchildren. Callosities and
metatarsus varus were the most frequently
occurring foot conditions detected in 54% and 46%
of Danish children, respectively. The prevalence of
foot pathologies of ingrown toenails and warts was
14 and 12 percent, respectively. The mean hallux
valgus angle was 3.7° (SD: 4.8), 5.6° (SD: 5.4) and
7.4° (SD: 5.5) in first, fifth and ninth grade,
respectively. The prevalence of callosities, ingrown
toenails, metatarsus, and hallux valgus increased
with age.
Interpretation / Conclusion: In conclusion, this study has shown that foot
pathologies such as warts and ingrown toenails.
Conditions such as Metatarsus varus and callosities
are common in Danish primary school children. Our
findings of high prevalences of foot pathologies and
conditions motivate future research projects to
clarify how this impacts general health and
subsequently the relation to pain, health challenges,
socioeconomics, and quality of life.
148. Patient-reported outcome following surgical treated ankle fractures not influenced by comorbidities - A cross-sectional study of 122 patient with 5-year follow-up
Christian Grundtvig Refstrup Rasmussen1, Peter Larsen2, Christian Pedersen1, Rasmus Elsoe1
1. Department of Orthopaedics, Aalborg University Hospital
2. Department of Psyiotheraoy, Aalborg University Hospital
Background: Ankle fractures are common injuries, 25-30 % of
patients are surgically treated. The patients show a
bi-modal distribution, with peaks in younger
individuals and older women. Consequently the
patients characteristics are heterogenous. The
current literature is inconclusive on the possible
associations between patient characteristics &
comorbidities and patient reported outcome.
Aim: The aim of this cross-sectional study was to
investigate the basic characteristics and
comorbidities of patients with surgically treated
ankle fractures and the associations to patient
reported outcomes.
Materials and Methods: This study was a retrospective cross-sectional
study including basic characteristics of surgically
treated ankle fractures. Patient-reported outcome
was derived by an online survey performed 5-6
years following surgery.
All adult Danish patients treated surgically for an
ankle fracture during 2017-2018 in the North
Denmark Region were identified and their basic
characteristics, fracture classification and
treatment were described. Furthermore their
level of comorbidities was established using the
Charlson Comobidity Score (CCS) based on
electronical medical records. Finally they were
invited, via E-boks, to complete the Foot and
Ankle Outcome Score (FAOS).
Results: We identified 280 adult Danish patients, with a
mean age of 54.2 years (18-96). Ninety percent
of the patients had a CCS of 0, 1 or 2. Among
the 280 patients 122 completed the FAOS (38
did not have E-boks, 120 did not respond after
two invitations). The age distribution and fracture
classification were similar between FAOS
responders and non-responders. The proportion
of non-responding males is markedly larger. The
122 patients reported mean FAOS subscales
scores, pain 77.0 (95% CI 3-100); symptoms
67.4 (95% CI 5-100); Activities of daily living 80.1
(95% CI 0-100); Sports & recreation 57.7 (95%
CI 0-100) and quality of life 61.2 (95% CI 0-100).
Using a one-way ANOVA analysis the differences
in comorbidities did not explain the differences in
patient reported outcome.
Interpretation / Conclusion: We did not find an association between
comorbidities and patient reported outcome in
patients who were surgically treated for an ankle
fracture.