[Bilateral stress fractures of the pelvic rami in a woman with anorexia nervosa].

This is a case report of a 51-year-old woman with bilateral stress fractures of the pelvic rami and a history of anorexia nervosa (AN). AN is a psychiatric condition of low weight caused by restricted food intake, impaired body image and an exaggerated fear of gaining weight in addition to compensating behaviour such as excessive physical activity. Among patients with AN, reduced bone density is common, and a higher risk of fractures is present. Stress fractures should be suspected in patients, who have AN and experience pain from the musculoskeletal system without a history of trauma.

Hip malformation is a very common finding in young patients scheduled for total hip arthroplasty.

INTRODUCTION: In Denmark, 20% of all registered total hip arthroplasties (THA) from 1995 to 2014 has been patients younger than 60 years with primary idiopathic osteoarthritis (OA). It is speculated that hip malformations may be a major contributor to early OA development. It has been shown that hip malformation may compromise implant position and, therefore, identifying and knowing the incidence of malformations is important. Our aim was to assess the prevalence and type of hip malformations in a cohort of younger patients undergoing THA. MATERIALS AND METHODS: In this prospective two center cohort study, 95 consecutive patients (106 hips) met the inclusion criteria. One observer performed radiographic measurements for malformations and radiographic OA. Inter- and intraobserver variability was assessed. RESULTS: From 95 patients (male n = 52 and female n = 43) age ranged from 35 to 59 years and prevalences of hip malformations were; CAM-deformity 50.9 and 25.5%, coxa profunda 33 and 27.4%, acetabular retroversion 33 and 29.2%, and acetabular dysplasia 10.4 and 3.8%. All patients showed minimum of one malformation. Prevalences of Tönnis grade 0-1 were 22.6% and 2-3 were 77.4%. CONCLUSION: All patients showed malformations, especially high prevalences were found for CAM-deformity, coxa profunda and acetabular retroversion. Identifying these malformations is fairly simple and recognizing the high prevalence may help surgeons avoid pitfalls during implant positioning in THA surgery. Further, focus on hip malformations may facilitate correct referral to joint-preserving surgery before OA develops.

[Can othopaedic surgeons accelerate time, or does the enthusiasm for alcohol rub just decrease by age?]

Senior surgeons can execute a full surgical hand antisepsis in no time. This could be due to a changed perception of time with age. This cross-sectional study secretly timed orthopaedic surgeons during alcohol rub, investigated their perception of 120 see and attitude towards hand antisepsis. Surgeons under 50 years of age used significantly longer time on alcohol rub. No significant difference in perception of neither time nor attitude towards surgical hand antisepsis were found between age groups. Surgeons are not affected by mental aging but seem to be able to accelerate time. Surgeons are aware of standard guidelines and follow them. This study presents new findings adding to the mythic nature of the orthopaedic surgeon.

[Orthopaedics' megalomania - myth or mobbing?]

INTRODUCTION: It is a general impression in the world of medicine that orthopaedic surgeons differ from doctors of other specialities in terms of intellect and self-confidence. The purpose of this study was to evaluate the self-confidence of orthopaedics. MATERIALS AND METHODS: We asked doctors from 30 different specialities to fill out a questionnaire. In addition to this, the participating orthopaedics were asked to rate their self-perceived surgical skills. RESULTS: In all, 120 orthopaedics and 416 non-orthopaedic doctors completed the questionnaire. There was no difference in GSE scores between orthopaedics and other doctors (p = 0.58). 98% of young orthopaedics estimated that their surgical talent was average or above average when compared with their colleagues on the same level of education. 72% believed that they were "equally talented", "more talented", or "far more talented" than their colleagues on a higher level of education. 76% believed that when assisting a senior surgeon the patients would "sometimes" (60%), "often" (14%) or "always" (2%) be better off if they were the ones performing the operation. More orthopaedics than non-orthopaedics believed that their speciality was regarded as one of the least important specialities in the world of medicine (p = 0.001). CONCLUSION: Orthopaedic surgeons in general are not more self-confident than other doctors or the average population, but young orthopaedic surgeons have a very high level of confidence in their own operation skills. FUNDING: none. TRIAL REGISTRATION: none.

No major effects of preoperative education in patients undergoing hip or knee replacement--a systematic review.

INTRODUCTION: The outcome of total hip (THA) and knee arthroplasty (TKA) may be optimised through preoperative patient education (PPE). It is hypothesised that PPE reduces anxiety, ensures realistic patient expectations and enhances post-operative outcome. The objective was to determine whether the literature supports a positive effect of PPE on post-operative outcomes including anxiety, pain, length of hospital stay (LOS), patient satisfaction, post-operative complications, mobility, and expectations. METHODS: PubMed and Embase searches were performed on 1 October 2014. Randomised studies of preoperative edu-cation (written, verbal and audiovisual) imparted by health professionals to patients were included. RESULTS: A total of twelve studies including 1,567 participants were identified. Six studies involved patients undergoing THA, five studies involved both THA and TKA, and one study TKA only. No convincing evidence in favour of PPE on outcomes regarding pain, LOS, patient satisfaction, post-operative complications, mobility and expectations was found. However, there was evidence for a reduction in preoperative anxiety. CONCLUSION: PPE has not been shown to affect post-operative outcomes - except for a significant reduction in preoperative anxiety. However, this conclusion may be flawed by the general heterogeneity of the pooled studies. Hence, there is a strong need for properly designed randomised and controlled studies that are sufficiently powered, performed in generalised optimised hospital settings including optimised logistics and clinical enhancements that allow for discrimination between outcome parameters.

Alternative outcome measures in young total hip arthroplasty patients: a prospective cohort study.

In this prospective multicentre cohort study we studied subjects younger than 60 years of age scheduled for primary total hip arthroplasty (THA). The study assessed patients' overall satisfaction, fulfillment of preoperative expectations, the effect on socioeconomic parameters, and quality of sex-life. Questionnaires including Oxford Hip Score (OHS) and SF-36 were evaluated preoperatively and 3, 6 and 12 months postoperatively. OHS and SF-36 showed significant improvements (p<0.028, Wilcoxon Signed Rank test). THA did not affect the patients' socioeconomic status. Increased frequency of intercourse or better abilities in intercourse positions were experienced by 18 of 39 females due to reduced pain and increased range of motion. Patients sexually active before THA surgery remained active. These findings constitute important new information to young patients and surgeons during the decision making process.

[Compartment syndrome of the foot]. / Kompartmentsyndrom i foden.

Compartment syndrome of the foot is a rare but nevertheless a very important limb-threatening condition which is generally caused by traumatic injuries. Diagnosis is made by recognising the common signs and symptoms: pain out of proportion, pain with passive stretch of the compartment, paraesthesias, and in worst case, paresis and missing pulse. Elevated pressure in one or several of the nine compartments in the foot confirms the diagnosis. When suspecting compartment syndrome acute fasciotomi is essential in order to prevent devastating complications such as nerve dysfunctions and foot deformities.

Cam deformity and hip degeneration are common after fixation of a slipped capital femoral epiphysis.

BACKGROUND AND PURPOSE: Slipped capital femoral epiphysis is thought to result in cam deformity and femoroacetabular impingement. We examined: (1) cam-type deformity, (2) labral degeneration, chondrolabral damage, and osteoarthritic development, and (3) the clinical and patient-reported outcome after fixation of slipped capital femoral epiphysis (SCFE). METHODS: We identified 28 patients who were treated with fixation of SCFE from 1991 to 1998. 17 patients with 24 affected hips were willing to participate and were evaluated 10-17 years postoperatively. Median age at surgery was 12 (10-14) years. Clinical examination, WOMAC, SF-36 measuring physical and mental function, a structured interview, radiography, and MRI examination were conducted at follow-up. RESULTS: Median preoperative Southwick angle was 22o (IQR: 12-27). Follow-up radiographs showed cam deformity in 14 of the 24 affected hips and a Tönnis grade>1 in 1 affected hip. MRI showed pathological alpha angles in 15 affected hips, labral degeneration in 13, and chondrolabral damage in 4. Median SF-36 physical score was 54 (IQR: 49-56) and median mental score was 56 (IQR: 54-58). These scores were comparable to those of a Danish population-based cohort of similar age and sex distribution. Median WOMAC score was 100 (IQR: 84-100). INTERPRETATION: In 17 patients (24 affected hips), we found signs of cam deformity in 18 hips and early stages of joint degeneration in 10 hips. Our observations support the emerging consensus that SCFE is a precursor of cam deformity, FAI, and joint degeneration. Neither clinical examination nor SF-36 or WOMAC scores indicated physical compromise.

Results of total joint arthroplasty and joint preserving surgery in younger patients evaluated by alternative outcome measures.

BACKGROUND: Knee and hip OA is the clinical and pathological outcome of a functional and structural failure of the joint, resulting in pain and physical dysfunction. Despite the similarity in clinical presentation the pathogenesis seems to differ. Where knee OA is associated with obesity and trauma, hip OA is associated with FAI covering three fundamentally different hip deformities, including acetabular dysplasia; all hypothesized to initiates OA development. Where PAO is used worldwide as a joint-preserving procedure in acetabular dysplasia, TKA and THA are the treatment of choice of end stage OA. Traditional main outcomes are clinically objective surgeon-reported endpoints. Patient perceived outcomes are known to differ from these and PROMs are now recommended as the core set of outcomes. When evaluating the outcome in younger patients, this high demanding group can show ceiling-effects of the scores. The overall aim of this thesis was to investigate the consequences of PAO, TKA, and THA in younger patients evaluated by alternative outcomes in relation to satisfaction, fulfillment of expectations, symptoms of depression, the socioeconomic effects, and abilities in sex-life; to improve patient information prior to PAO, TKA and THA surgery. MATERIAL AND METHODS: This PhD thesis is based on three studies. Study I is a cross-sectional survey of preserved hip joints with a mean follow-up of ten years after PAO. One hundred patients (121 PAO's) were eligible for inclusion. An inquiry to the National Patient registry identified 36 of PAO's (in 35 patients) being converted to THA. The 61 remaining patients (80 preserved hip joints) were asked to participate in this questionnaire based follow-up. Fifty-five patients (70 preserved hip-joints) accepted and constituted the study population. All patients received a questionnaire concerning aspects of functional ability, patient satisfaction, expectations, and quality of life following PAO. Both Study II and Study III are prospective multicenter cohort studies. Consecutive patients less than 60 years of age scheduled for (study II) unilateral or bilateral simultaneous primary TKA or (study III) scheduled for unilateral or bilateral simultaneous primary THA or HR were eligible for inclusion. Study II consisted of 115 primary TKA patients; 103 unilateral and 12 simultaneous, and Study III consisted of 136 primary THA patients; 86 unilateral THA, six simultaneous bilateral THA, and 44 HR. The study groups received a paper-format questionnaire within one month before surgery and at three, six, and 12 months postoperatively. RESULTS: Study I showed a high willingness to undergo PAO again with the experience and knowledge they have today and improvements were seen in all quality of life parameters except for ability in sex-life for males. Study II showed significantly improvements in joint function and HRQoL. Satisfaction and fulfillment of expectations do, however, not fully mirror the observed significant improvements in knee function and HRQoL. Patients with a depression preoperatively experience an inferior result evaluated by OKS and SF-36 PCS and MCS, but not concerning satisfaction, work-life, income or sex-life. In general TKA surgery in younger patients cannot be expected to change relation to work or annual income. Patients stay sexually active after TKA, but a decrease in frequency and a negative affection of sexual practice should be expected. Study III showed significantly improvements in joint function and HRQoL and a high degree of satisfaction and fulfillment of expectations. Only patients with major complications were not willing to repeat. THA surgery in younger patients cannot be expected to change the patient's relation to work or annual income. Patients stay sexually active after THA, and female patients experiences positive changes. CONCLUSION: Based on the findings in this thesis PAO patients are satisfied with the outcome at medium to long-term follow-up, and lasting improvements is seen in the patients' sex life, ability to do sports, and social life. TKA and THA are reliable surgical procedures in younger patients. In addition to significantly improving joint function and HRQoL, patients' stay employed and sexually active postoperatively. However, a decrease in frequency of sexual activities and negative affection of sexual practice patterns should be anticipated following TKA surgery, THA surgery have a positive influence on female THA patients sex-life.

Does bony hip morphology affect the outcome of treatment for patients with adductor-related groin pain? Outcome 10 years after baseline assessment.

BACKGROUND: Adductor-related groin pain and bony morphology such as femoroacetabular impingement (FAI) or hip dysplasia can coexist clinically. A previous randomised controlled trial in which athletes with adductor-related groin pain underwent either passive treatment (PT) or active treatment (AT) showed good results in the AT group. The primary purpose of the present study was to evaluate if radiological signs of FAI or hip dysplasia seem to affect the clinical outcome, initially and at 8-12 years of follow-up. METHODS: 47 patients (80%) were available for follow-up. The clinical result was assessed by a standardised clinical outcome combining patient-reported activity, symptoms and physical examination. Anterioposterior pelvic radiographs were obtained and the centre-edge angle of Wiberg, α angle, presence of a crossover sign and Tönnis grade of osteoarthritis were assessed by a blinded observer using a reliable protocol. RESULTS: No significant between-group differences regarding the distribution of radiological morphologies were found. There was a decrease over time in clinical outcome in the AT group with α angles >55° compared to those with α angles <55° (p=0.047). In the AT group, there was no significant difference in the distribution of Tönnis grades between hips that had an unchanged or improved outcome compared with hips that had a worse outcome over time (p=0.145). CONCLUSIONS: No evidence was found that bony hip morphology related to FAI or dysplasia prevents successful outcome of the exercise treatment programme with results lasting 8-12 years. The entity of adductor-related groin pain in physically active adults can be treated with AT even in the presence of morphological changes to the hip joint.

Total knee arthroplasty in younger patients evaluated by alternative outcome measures.

In this prospective multicenter study we included subjects younger than 60 years of age and scheduled for primary total knee arthroplasty (TKA). The study assessed patients' overall satisfaction, fulfillment of preoperative expectations, the effect on socioeconomic parameters, and quality of sexual life. Questionnaires including Oxford Knee Score (OKS) and SF-36 were evaluated preoperatively and 3, 6, and 12 months postoperatively. OKS and SF-36 showed significant improvements. However, patient satisfaction and fulfillment of personal expectations did not reflect these scores. Overall, TKA did not affect the patients' socioeconomic status, and overall, patients did not experience impairment of sexual life, but decreased frequency and negative affection of sexual practice should be anticipated. Alternative outcome measurements of TKA surgery not focusing on implants and surgical techniques shed new light on important consequences of arthroplasty surgery.

Periacetabular osteotomy: sporting, social and sexual activity 9-12 years post surgery.

Hip joint survivorship and functional outcome are traditional outcome measures applied after periacetabular osteotomy (PAO). Younger adults however have greater demands and expectations on the function of their hip joints and these demands are not expressed using traditional outcome assessment tools. The main purpose of this study was to explore alternative functional and quality of life measure after PAO.A cross sectional survey of preserved hip joints following PAO was performed. Fifty-two patients (68 hips), mean age 41 years (range 24-67), returned a questionnaire examining satisfaction, willingness to repeat surgery, quality of life, abilities in social activities, sports and sex-life, pain, limp, and stability of the hip.Median satisfaction was 5 (range 1-5) and 44 of 49 patients were willing to repeat surgery. Significant improvements were seen in quality of life, ability to do sports, participate in social activities and sex-life (p values <0.001) (although sex-life for males (p = 0.102)). Traditional outcomes (pain, stability and limp) showed significant improvements (p<0.001). Lasting improvements in patients' sex life, social life and ability to do sports nine to 12 years following PAO were reported. Such factors are important measures of outcome in a younger adult cohort.

Validity and reliability of the Achilles tendon total rupture score.

The best treatment of acute Achilles tendon rupture remains debated. Patient-reported outcome measures have become cornerstones in treatment evaluations. The Achilles tendon total rupture score (ATRS) has been developed for this purpose but requires additional validation. The purpose of the present study was to validate a Danish translation of the ATRS. The ATRS was translated into Danish according to internationally adopted standards. Of 142 patients, 90 with previous rupture of the Achilles tendon participated in the validity study and 52 in the reliability study. The ATRS showed moderately strong correlations with the physical subscores of the Medical Outcomes Study 36-item Short-Form Health Survey (r = .70 to .75; p < .0001) and Victorian Institute of Sports Assessment-Achilles questionnaire (r = .71; p < .0001). Test-retest of the ATRS showed no significant difference in the mean (2.41; p = .07). The limits of agreement were ±18.53. A strong correlation was found between test and retest (intercorrelation coefficient .908); the standard error of measurement was 6.7, and the minimal detectable change was 18.5. The Danish version of the ATRS showed moderately strong criterion validity. For study and follow-up purposes, the ATRS seems reliable for comparisons of groups of patients. Its usability is limited for repeated assessment of individual patients. The development of analysis guidelines would be desirable.

The prevalence of predisposing deformity in osteoarthritic hip joints.

It is becoming increasingly evident that hip joint deformities may be major contributors to the development of osteoarthritis, and the term 'idiopathic osteoarthritis' may be inappropriate in many cases. Our study cohort was derived from the Copenhagen Osteoarthritis Sub-study, a cross sectional population-based database of 4151 individuals, all of whom had a standard anteroposterior weight-bearing pelvic radiograph taken. Hip joints were classified according to type and degree of deformity. We defined hip osteoarthritis by a minimum joint space width of < or = 2 mm. This cut-off has a significant relationship in both sexes with the clinical presentation. The study cohort which fulfilled these inclusion criteria consisted of 322 females (149 right hips and 173 left hips) and 162 males (77 right hips and 85 left hips) with osteoarthritis. We found an overall prevalence of predisposing hip deformities in females of 62.4% and in males of 78.9%. Minor and major deformities showed the same prevalence. Both sexes had a comparable prevalence of minor and major hip joint deformity, except for pistol grip deformity, which was more prevalent in men. We concluded that 'idiopathic osteoarthritis' is uncommon, and that even minor predisposing deformities are associated with hip osteoarthritis.

[Renal effect of treatment for heart failure]. / Nyrepåvirkning ved behandling af hjertesvigt.

The case of a 66-year-old male with heart failure and cardiorenal syndrome is presented. The patient had normal renal function before intensive treatment with diuretics and ACE inhibitor. Shortly after the ACE inhibitor was stopped and diuretics were either stopped or reduced in dosage, his renal function normalized. Suggestions are presented for follow-up after initiation of ACE inhibitor treatment.