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.