Annual Report 2015 Academic AcƟvies

Department of Orthopaedic Surgery

www.ahus.no

Annual report 2015

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Annual report 2015

CONTENTS

CONTENTS .........................................................................................................3 ORTOPAEDIC RESEARCH COMMITTEE 2015 .................................................5 Summary of Research AcƟvity ...................................................................................... 6

ORTOPAEDIC RESEARCH GROUP ...................................................................7 THE RESEARCH YEAR 2015 IN REVIEW ..........................................................8 CARTILAGE, TENDON AND LIGAMENT INJURIES ......................................10 DISSERTATIONS .............................................................................................12 Jan Harald Myhreng RøƩerud .........................................................................12 Aron Adelved ...................................................................................................14 MASTER THESIS .............................................................................................14 Jan Rune Mikaelsen .........................................................................................14 ONGOING RESEARCH PROJECTS .................................................................15 Fractures in children ................................................................................................... 15 Spinal injuries ............................................................................................................. 18 Upper extremity ......................................................................................................... 22 Lower extremity ......................................................................................................... 30 InnovaƟon projects .................................................................................................... 52

PRESENTATIONS ............................................................................................53 a. b.

Abstracts and posters ....................................................................................... 53 Academic assignments ..................................................................................... 53

PUBLICATIONS ...............................................................................................58 a. b. c. d.

Peer-Reviewed publicaƟons ............................................................................. 58 Abstracts .......................................................................................................... 58 Book Chapters .................................................................................................. 59 Commentary & PerspecƟve ............................................................................. 59

IN MEDIA........................................................................................................77 NURSING PROJECTS ......................................................................................78 a.

PresentaƟons .................................................................................................... 78

RESEARCH FUNDING 2015............................................................................79 a. b.

DistribuƟon of research funding in Orthopaedic Research Group .................... 79 Overview of funding for each project ............................................................... 79

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Annual report 2015

ORTOPAEDIC RESEARCH COMMITTEE 2015 Head Sec on Chief of children`s foot fractures Dept. of S205 Orthopaedic Nursing, Head Dept. of Orthopaedic Surgery, Physician Dept. of Orthopaedic Surgery, Physician Research Coordinator

Asbjørn Årøen Anders Wensaas Wenche Bjerkestrand Jacobsen Truls M. Straume-Næsheim Per-Henrik Randsborg Nina Mickelson Weldingh

Orthopaedic Research Committee. Left to right: Nina M Weldingh, Truls Martin Straume-Næsheim, Asbjørn Årøen, Anders Wensaas, Wenche Bjerkestrand Jacobsen. Not present on the day of photography: Per-Henrik Randsborg. Foto: Helen Anderson

The principal tasks of the commiƩee are to: ●

Promote research and research training for all workers in the Orthopaedic Clinic;

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Develop research ac vi es, research quality, and publica on frequency within the Orthopaedic Research Group;

●

Improve the communica on of orthopaedic research and published results from the group;

●

Ensure that research is maintained as a high priority within the division.

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Annual report 2015 Summary of Research AcƟvity Peer-reviewed publicaƟons and dissertaƟons of members of the Department of Orthopaedic Surgery in the last five years.

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Annual report 2015

ORTOPAEDIC RESEARCH GROUP Research Fellows:

Head: Professor Asbjørn Årøen Research posiƟons and PhD students University employees: Professor II Asbjørn Årøen Associate Professor Stein Erik Utvåg Associate Professor Truls M. Straume-Næsheim

Stein Erik Utvåg Ulf Erik Sigurdsen Jan Harald Rø erud (PhD student) Ola-Lars Hammer (PhD student) Svend Ulstein (PhD student) Anders Wensaas (PhD student) Cathrine Nørstad Engen (PhD student UiO) Truls M. Straume-Næsheim (Postdoc) Inge Skråmm Sigurd Erik Hoelsbrekken Ingi Thor Hauksson Morten Havdal Per-Henrik Randsborg Ståle Clementsen Aron Adelved (PhD student) Stefan Bartels (PhD student) Hendrik Fuglesang (PhD student) Filip C. Dolatowski (PhD student) Chris an Owesen (PhD student) Ståle Myhrvold (PhD student) Chris an Pollmann Espen Femmo Brouwer

D-posiƟons: Svend Ulstein – ligament and car lage injuries Chris an Owesen – cruciate ligament injuries University candidate with a teaching duty of 100% Hendrik Fuglesang – clavicular fractures University candidate with a teaching duty of 50% Ola-Lars Hammer - distal radius fractures

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Annual report 2015

THE RESEARCH YEAR 2015 IN REVIEW

Orthopaedic Research Group Left to right, front: Jan Harald Røtterud, Ståle Myhrvold, Ingi Thor Hauksson, Asbjørn Årøen, Left to right, middle: Truls Martin Straume-Næsheim, Inge Skråm, Erik Engebretsen, Sjur Oppebøen, Left to right, back: Nina M. Weldingh, Christian Pollman, Aron Adelved, Anders Wensaas. Foto: Helen Anderson

2015 has come to an end, and our Strategic Plan for Research, 2011–2016 is within its final year. It is noted that most of the aims in the previous plan have been achieved, and if this progress is con nued, our group will develop into a major contributor to the field of orthopedic research in the upcoming years. Knowledge made possible through research can not take place for free, and as such in 2016 it is necessary for the research group to con nue to compete for external and internal research funding. This is mandatory in order to be able to complete ongoing projects, to recruit new researchers to the group and to fulfill the main goal of the group, which is to increase its publica on rate in the most highly ranked journals. One of the main goals for the group has been to take the role of principle inves gator in more mul center projects, as this is needed in order to gather the amount of data needed to find answers to the most difficult problems in our field. One of the group’s major achievements in 2015 was receiving a research grant of 19 million NOK from the Norwegian Research Council for the Norwegian Car lage Project (NCP), a mul center project involving seven Norwegian hospitals. This funding directly resulted in a new postdoc posi on held by Per-Henrik Randsborg and the recruitment of Heidi Andreassen Hanvold as project coordinator. Together with the rest of the research group, they have put in a tremendous effort enabling this large project to start including its first pa ents on 20.01.16. On the other hand, 2015 resulted in a small drop in our publica on rate, but measures have been ini ated to enable senior researchers in the group to reverse this trend. However,

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Annual report 2015

it has not been a silent year for the research group, with two disserta ons by Jan Harald Rø erud on “Focal car lage lesions in anterior cruciate ligament-injured knees” and Aron Adelved on “Long-term Func onal and Radiological Outcome a er Displaced Sacral Fractures” in addi on to our internal research seminar in June and the annual external research seminar in September. The la er was combined with the ini a on mee ng for the Norwegian Car lage Project, and the mee ng as such had the highest number of par cipants ever, indica ng that this is an important mee ng for our collaborators in primary health care. Personally, the last year has been hampered by almost a year of sick leave due to a brain stroke. However the group has been fantas c in con nuing its work in my absence, indica ng that we have developed into a strong team. In 2016, collabora ve efforts will also be a major factor for furthering the development of our research, and the plan is to ini ate both ingoing and outgoing clinical and research fellowships to strengthen our interna onal collabora ons. Best regards, Professor Asbjørn Årøen Head of Research, Orthopaedic Clinic and Leader of Ahus Orthopaedic Research Group

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Annual report 2015

CARTILAGE, TENDON AND LIGAMENT INJURIES The Department of Orthopaedic Surgery Research Day Ahus September 24th, 2015

This year’s Orthopaedic Research Symposium was led by the Orthopaedic Clinic`s ac ng head of research, Truls Mar n Straume-Næsheim. The focus on this year’s external research seminar was car lage, tendon and ligament injuries, with a par cular focus on knee injuries. It was the second year in which the symposium was held as an external seminar aimed at local health service providers. The symposium was fully booked with over 119 par cipants and several on the wai ng list. The program a racted orthopaedic surgeons as well as physiotherapists, radiologists, radiographers, primary physicians, chiropractors and nurses. The introduc on was held by Truls M. Straume-Næsheim, who presented the research group and who introduced the focus of the seminar with an interes ng lecture on knee pain experienced by the ac ve athlete. The organizers had invited par cipants from “The Norwegian Car lage Project” to lecture about their topics. From Kris ansund Hospital, orthopaedic surgeon Tommy Frøseth Aae and Head of Surgery, Øystein Lian, gave an interes ng lecture on PRP and tendons, and PRP and osteoarthri s, respec vely. Furthermore, an orthopaedic surgeon from Haukeland University Hospital reported on “Jumper`s knee,” ques oning whether “jumper`s knee should be treated with PRP or other treatments.” There were also several lectures on car lage presented from different perspec ves. An orthopaedic surgeon from Drammen Hospital contributed an informa ve update on different treatments of knee car lage injuries. Researcher and Head of the Ins tute of Immunology, Rikshospitalet, Jan E. Brinchmann managed to make the theore cal and complex topic of car lage research in the cell lab both understandable and incredibly interes ng for surgeons and primary care health workers alike. Furthermore, Professor and Head of Research at Ullevål, Lars Engebretsen talked about how we use this research in our clinical prac ces. A er a social lunch break, physiotherapist Turid Høysveen from Ullernklinikken shared her experiences with rehabilita ng pa ents a er a car lage injury. We were also very lucky to have radiologist Hasan Banitalebi, Ahus, give an informa ve lecture on the radiological evalua on of car lage. Finally, Per-Henrik Randsborg, principal inves gator in “The Norwegian Car lage Project,” Ahus, completed the seminar with a presenta on of the mul center na onal car lage research project.

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We wish to give our great thanks to all of the guest lecturers, who did an excellent job in providing all of the aƩendees of our seminar with their impressive professional knowledge. Furthermore, we wish to acknowledge Asbjørn Årøen and Truls M. Straume-Næsheim for puƫng together the program for another successful seminar.

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DISSERTATIONS

Jan Harald Myhreng RøƩerud Focal carƟlage lesions in anterior cruciate ligamentinjured knees—Incidence, risk, prognosis and treatment. Main supervisor: Asbjørn Årøen DissertaƟon: 6. Mar. 2015, Akershus Universitetssykehus, Lørenskog. Jan Harald Myhreng Rø erud has shown that the current treatments of pa ents with damage to the knee’s anterior cruciate ligament (ACL) combined with damage to the ar cular car lage are underperforming. Injury to the knee’s ACL combined with damage to the ar cular car lage o en leads to poor knee func on. These injuries o en affect younger sports- and labor-ac ve individuals. Op mal treatments will provide improved quality of life for pa ents and reduced costs for society. Rø erud and colleagues used data from the Na onal ACL registries in Norway and Sweden and analyzed data from up to 16,000 pa ents with ACL injuries. This is one of the largest pa ent materials ever inves gated in this field. In this work, Røtterud and colleagues have shown that patients with ACL and cartilage injuries indicated that they had poorer knee func on two years a er ACL surgery in contrast to pa ents without concomitant car lage. Car lage damage was not treated surgically in approximately half of the pa ents, while the remaining pa ents were mainly treated with surgical debridement or microfracture. Debridement gave no effect and microfracture gave poorer results than no treatment. The results indicate that one should be very restric ve with microfracture of these car lage damages. Furthermore, Rø erud found that men in general and male handball players in par cular are more suscep ble to these combined injuries.

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Annual report 2015

Aron Adelved Long-term FuncƟonal and Radiological Outcome aŌer Displaced Sacral Fractures.

Main supervisor: Olav Røise, Universitetet i Oslo DissertaƟon 15. Apr. 2015, Akershus Universitetssykehus, Lørenskog Physician and researcher Aaron Adelved have found that pa ents with sacral fractures with malposi on have significant sequela many years a er their injuries. The sacrum forms the rear por on of the pelvic girdle. Sacral fractures with malposi on are a rare and serious injury that occur in high-energy collisions such as traffic accidents or falls from heights. The nerves that supply the pelvic and lower extremi es emanate from the spinal cord and come out through the sacrum and are thus in great danger of injury in a fracture with malposi on, with consequent malfunc on in the lower extremi es or pelvic organ. Significant impairment and pain shortly a er such damage is well-described in several previous studies. Long-term results and change of disabili es over me are, however, very underexplored. In his disserta on, “Long-term Func onal and Radiological Outcome a er Displaced Sacral Fractures,” Aaron Adelved and his colleagues studied 28 pa ents operated on for sacrum fractures with malposi on in a ten-year follow-up. Another group (13 pa ents) with an unusual type of sacrum fracture called trauma c lumbosacral dissocia on was also studied in a seven-year follow-up. The study shows that the pa ents are struggling with nerve outcome in the lower extremi es, pain, poor bladder func on and sexual dysfunc on. Furthermore, they have low self-reported health and high percentages of incapacity. No associa ons were found between pain and residual malposi on of the pelvic ring or sacrum or any other clinical or radiological findings. The comparison of ten-year results with one-year results revealed a worsening bladder func on in a significant propor on of pa ents, but no significant changes of the other impairments were observed.

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Annual report 2015

MASTER THESIS

Jan Rune Mikaelsen Delayed emergency surgery Er dagkirurgisk behandling et godt alternaƟv Ɵl ortopedisk akuƩkirurgi?

Main supervisor: Tor Iversen Oral exam: 12. Jan. 2016, Oslo University

Emergency surgery is required for many pa ents suffering from acute trauma. However, not all emergency trauma need acute surgery, but can be managed with delayed emergency surgery. Ankle fractures are common injuries affec ng all age groups and cons tute a large propor on of the orthopedic trauma load. Pa ents are usually admi ed directly to the ward from the emergency department and a large number of bed –days are spent wai ng to the ankle swelling to subside prior to surgery. We audited current prac ce and then implemented a home therapy programme. The purpose of the study was to assess home therapy with respect to cost effec veness, length of stay and quality. The results indicate a difference in cost and length of stay. With pa ents in whom it is indicated, the home therapy ankle pathway has proved to be a safe and resource sparing method of managing ankle fractures prior to surgery.

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ONGOING RESEARCH PROJECTS Fractures in children A quanƟficaƟon of the socioeconomic cost of a pediatric fracture clinic in Akershus, Norway. Project group: Main researcher: Anne Holm, MD, Oslo University Hospital Supervisor: Per-Henrik Randsborg, MD, PhD, Akershus University Hospital Research group: Hilde Lurås, PhD, Akershus University Hospital IntroducƟon: Pediatric fractures are common and frequently followed up on in the fracture clinic. The socioeconomic impact of these follow-ups on the families and the society as a whole is largely unknown. Aim: To quanƟfy the direct and indirect cost of aƩending a scheduled follow-up of a pediatric fracture of the upper limb. Materials and methods: 295 paired parent and surgeon quesƟonnaires were collected from consecuƟve scheduled follow-ups of pediatric fractures of the upper limb over a seven-month period. Current status: SubmiƩed (December 2015) PublicaƟons: A quanƟficaƟon of the socioeconomic cost of a pediatric fracture clinic in Akershus, Norway. Funding: Ahus Internal Strategical Research funding A comparison of the level of physical acƟvity in children with fractures compared to children who never sustained a fracture, as measured by the Physical AcƟvity QuesƟonnaire for children (PAQ-c). Project group: Research group: Per-Henrik Randsborg, MD, PhD, Akershus University Hospital Jan Harald RøƩerud, MD, PhD, Akershus University Hospital IntroducƟon: Fractures in children are common and their incidence has increased over the last decades. This increase has been linked to an increase in physical acƟvity, and physical acƟvity has been idenƟfied as an independent risk factor for pediatric fractures. Aim: To compare the level of physical acƟvity as measured by the PAQ-c quesƟonnaire in children who aƩend the fracture clinic with an acute fracture versus children who have never sustained a fracture. Materials and methods: 800 children aged 6–13 with an acute fracture are compared with 153 children of the same age group who have never sustained a fracture. 15

Annual report 2015 Current status: Analyzing and wriƟng of the manuscript. Planned submission first half of 2016. PublicaƟons: A comparison of the level of physical acƟvity in children with fractures compared to children who have never sustained a fracture, as measured by the Physical AcƟvity QuesƟonnaire for children (PAQ-c). Funding: Ahus Internal Strategical Research Funding Fractures in children: Distal radius fractures in paƟents younger than 16. Are they classified and treated according to internal guidelines? A quality control project. Project group: Primary researchers: Tor KrisƟan Molstad Andresen, MD; Øystein Sandnes, MD; Rune B. Jakobsen, MD, PhD, Akershus University Hospital Supervisor: Per-Henrik Randsborg, MD, PhD; Rune B. Jakobsen, MD, PhD, Akershus University Hospital IntroducƟon: Fractures of the distal radius are common in children. More than 500 such fractures are treated at Akershus University Hospital each year. This amounts to a significant part of the total volume of paƟents treated at the emergency ward (Skadelegevakten). Previously Randsborg and Sivertsen have studied the epidemiology of these fractures and found that buckle-type fractures may be treated conservaƟvely with a forearm cast, which the paƟent or parents remove without any follow-up appointments, as opposed to other types of distal radius fractures that are generally treated conservaƟvely, but with follow-up at one and four to six weeks due to the risk of displacement and malunion. These findings were incorporated into the hospital’s internal guidelines and included in the manual for the emergency ward, which was made available in the department March 2013. It is not known to what extent these changes are reflected in the actual treatment delivered. Aim: Internal quality control of the conservaƟve and operaƟve treatment of distal radius fractures in children under the age of 16. 1. Are fractures classified correctly (buckle, greensƟck, complete, physeal [Salter-Harris])? 2. Are they treated according to internal guidelines, with specific focus on buckle and greensƟck fractures and the number of scheduled controls? 3. Are there any complicaƟons during the first year aŌer the iniƟal trauma? Materials and methods: PaƟents aged 0–15 have been idenƟfied from their ICD-10 codes (S52.5) for the full year between September 2014 and 2015. PaƟents not residing in the area served by AHUS were excluded. PaƟent characterisƟcs, treatment and complicaƟons are idenƟfied from the electronic medical records by one of the researchers, and x-rays are independently classified by two of the involved researchers. StaƟsƟcs will be mainly descripƟve. Inter-rater agreement will be assessed by standard kappa-staƟsƟcs. Current status: Data acquisiƟon in progress. PublicaƟons: Results from the study will be published in an internaƟonal peer-reviewed journal of orthopedic surgery. Funding: No specific funding.

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Annual report 2015 Slipped capital femoral epiphysis Project group: Main researcher: Anders Wensaas MD, PhD student, Akershus University Hospital Main supervisor: Terje Terjesen, Prof., Oslo University Hospital, Rikshospitalet Co-supervisor: Svein Svenningsen, Orthopaedic Department, Sørlandet Hospital, Arendal

1. Long-term outcome a er slipped capital femoral epiphysis Aim: To evaluate long-term radiological and clinical outcome a er slipped capital femoral epiphysis. Materials and methods: Pa ents: Sixty-six pa ents treated for SCFE at Sophies Mindes Hospital with a minimum follow-up of 20 years. Method: Radiological and clinical follow-up examina on. Outcome-measurements: Radiological: Osteoarthri s (total hip replacement) Clinical: HHS/ EQ-5D Design: Retrospec ve Current status: Published Wensaas, A., Svenningsen, S., Terjesen, T. Long-term outcome of slipped capital femoral epiphysis: a 38-year follow-up of 66 paƟents. J Child Orthop (2011) 5:75–82

2. Femoroacetabular impingement a er slipped capital femoral epiphysis Aim: To determine the reliability of radiological measurements of deformity and the long-term clinical and radiological consequences of persistent deformity following SCFE. Materials and methods: Pa ents: fi y pa ents who a ended for long-term review a er SCFE (study 1). Methods: The post-slip deformity was evaluated by five different radiological measurements (femoral head ra o, lateral femoral head ra o, alpha angle in AP and lateral view, anterior femoral head-neck offset ratio). Outcome measurements: Radiological: Osteoarthri s (total hip replacement). Clinical: Harris Hip Score. The inter/intraobserver agreements were evaluated by limits of agreement (LOA) and intra-class correla on coefficient (ICC). Design: Retrospec ve. Current status: Published. Wensaas, A., Gunderson, R.B., Svenningsen, S., Terjesen, T. Femoroacetabular impingement aŌer slipped capital femoral epiphysis. The radiological diagnosis and clinical outcome at long-term follow-up. J Bone Joint Surg (Br) 2012 94-B;11:1489–93.

3. Long-term outcome of the untreated contralateral hip in slipped capital femoral epiphysis Aim: To determine the frequency of radiographic signs of femoroacetabular impingement (FAI), indicating previous slip in the untreated contralateral hip, in pa ents with unilateral SCFE. To evaluate the long-term natural history of the contralateral hips with signs of FAI and in hips without such signs. 17

Annual report 2015 Materials and methods: PaƟents: Forty paƟents treated for unilateral SCFE (based on the study-populaƟon in Study 1). Methods: Post-slip deformity and FAI were evaluated with the alpha-angle in AP and lateral view. Outcome-measurements: Radiological: OsteoarthriƟs (total hip replacement). Clinical: The paƟents were evaluated by telephone-interview and a modified Harris Hip Score was used since range of moƟon and deformity could not be examined. Design: RetrospecƟve. Current status: Published. Wensaas, A., Gunderson, G.B., Svenningsen, S., Terjesen, T. Good long-term outcome of the untreated contralateral hip in unilateral slipped capital femoral epiphysis. J Child Orthop (2014) 8:367–373.

4. MRI in slipped capital femoral epiphysis; can it predict subsequent contralateral slip Aim: To evaluate if MRIs can predict subsequent slips in unilateral SCFE. Materials and methods: PaƟents: Twenty paƟents treated for primarily unilateral SCFE. Methods: InterpretaƟon of MRI taken at diagnosis to evaluate if there were any signs that could predict subsequent slip. Design: ProspecƟve cohort. Current status: Inclusion and follow-up finished.

Spinal injuries The NORDSTEN-trial, a randomized mul center study comparing different surgical procedures in pa ents with spinal stenosis with or without degenera ve slip. Project group: ScienƟfic Board: Leader: ChrisƟan Hellum, PhD/Consultant, Orthopedic Surgeon, Oslo University Hospital. Members: KjersƟ Storheim, ScD/Assistant Professor at Oslo University Hospital, FORMI (a CommunicaƟon and Research Unit in the Division of Neuroscience, Oslo University Hospital); Kari Indrekvam, Clinical Director/ Chief Surgeon/Assistant Professor, Haukeland University Hospital; Jens Ivar Brox, Professor/Consultant Physical Medicine, Oslo University Hospital; Oliver Grundnes, MD/Consultant Orthopedic Surgeon, Akershus University Hospital; Tore Solberg, PhD/Assistant Professor/Consultant Neurosurgeon, University Hospital of North Norway; Ivar Magne Austevoll, Consultant Orthopedic Surgeon/PhD student, Haukeland University Hospital; Erland Hermansen, Consultant Orthopedic Surgeon/PhD student, Aalesund Hospital; Frode Rekeland, Consultant Orthopedic Surgeon, Haukeland University Hospital AdministraƟve ExecuƟve Board: Leader: Kari Indrekvam, Clinical Director/Chief Surgeon/Assistant Professor, Haukeland University Hospital Members: Berit Kvalsvik Teige, PhD/Head of R&D unit, More and Romsdal Health Trust; KjersƟ Storheim, ScD/Assistant Professor at Oslo University Hospital, FORMI; ChrisƟan Hellum, PhD/Consultant Orthopedic Surgeon, Oslo University Hospital; Erland Hermansen, Consultant Orthopedic Surgeon/PhD student, Aalesund Hospitaland; Ivar M. Austevoll, Consultant Orthopedic Surgeon/PhD student, Haukeland University Hospital 18

Annual report 2015 Working Commi ee/Par cipa ng Hospitals: Leader: Erland Hermansen, Consultant Orthopedic Surgeon/PhD student, Aalesund Hospital. Members: One surgeon and one study coordinator from each parƟcipaƟng hospital. ParƟcipaƟng hospitals: Aalesund Hospital, Hagevik Hospital, Haukeland University Hospital, Stavanger University Hospital, Oslo University Hospital, Akershus University Hospital, St. Olav University Hospital, University Hospital of North Norway, Levanger Hospital, Lillehammer Hospital, Gjøvik Hospital, Bærum Hospital, MarƟna Hansen Hospital, Drammen Hospital, Skien Hospital, Arendal Hospital The sub-studies: The three sub-studies each have a project manager: SST: Erland Hermansen, Consultant Orthopedic Surgeon/PhD student, Aalesund Hospital DST: Ivar Magne Austevoll, Consultant Orthopedic Surgeon/PhD student, Haukeland University Hospital OC: Frode Rekeland, Consultant Orthopedic Surgeon, Haukeland University Hospital IntroducƟon: The trial consists of three different arms:

1. SST-arm: Lumbar Spinal Stenosis arm 2. DST-arm: Lumbar DegeneraƟve Spondylolisthesis arm 3. OC-arm: ObservaƟonal Cohort In this trial, we dis nguish between Lumbar Spinal Stenosis (LSS) and Lumbar Degenera ve Spondylolisthesis (LDS). These two condi ons are handled in two separate pathways. We also have an Observa onal Cohort, consis ng of pa ents that suffer from the LSS radiologically, but do not have sufficient amount of symptoms to jus fy surgery. Brief Summary: Spinal Stenosis in the lumbar region without a verified slip is named Lumbar Spinal Stenosis (LSS). When an addi onal slip occurs, the condi on is named Lumbar Degenera ve Spondylolisthesis (LDS). Both are common in the elderly popula on; and with an increasing elderly popula on, handling these condi ons poses an increasing challenge to our health service. Surgical treatment for these diseases is considered superior to nonsurgical treatment. This is documented in numerous trials and review ar cles, including a Cochrane Review. However, there are some ques ons that remain unanswered. The main issue in the LSS-arm is to find which surgical procedure will give the best short-term and long-term results and to quan fy the degree of decompression required to maintain the best results. In the LDS-arm, the main issue is whether a fusion in addi on to a midline-preserving decompression is needed to maintain the best results. In the Observa onal Cohort (OC) we want to inves gate whether there are characteris cs in the symptomatology or radiological findings that can explain why some of the pa ents have milder clinical symptoms. The number of pa ents that require surgical treatment at a later stage will be noted. We have received an approval from the Norwegian Commi ees for Medical and Health Research Ethics (2011/2034 and 2013/366). Aim: The main objec ve of the study is to find which choice of treatment gives the best clinical results evaluated by Pa ent Reported Outcome Measurements (PROM). Primary outcome: In the two surgical arms, the primary outcome is a measurement of the change of ODI (version 2.0) a er two, five and ten years. In the OC-arm, the primary outcome is me-to-opera on or whether the pa ents require surgical treatment. Secondary outcomes: In the two surgical arms, the secondary outcomes are changes in EQ-5D, ZQS-score, NRS for LBP, NRS for leg pain, and self-evaluated effect of surgery. All of these PROM-ques onnaires have been evaluated in several studies [25-27]. Differences according to surgical methods will also be registered. Complica ons, opera on me, blood loss and length of stay are all outcomes that will be reported. In the OC-arm the secondary outcome is to register change in clinical parameters, measured by ODI, EQ-5D, ZQS-score, NRS for LBP and NRS for leg pain. 19

Annual report 2015 Materials and Methods: Inclusion and exclusion criteria Both sexes are eligible for inclusion. Please note that all criteria are the same for all three arms, except the presence of a verified slip in the affected level of 3 mm or more (exclusion for LSS, inclusion for LDS). For the OC-arm, we do not have a dis nc on between verified slip or not, nor do we have any demands of ODI-score ≥25. Inclusion criteria for the NORDSTEN-trial:

SST-arm

DST-arm

OC-arm

Have clinical symptoms of spinal stenosis as neurogenic Yes claudica on or radia ng pain into the bilaterally to the lower limbs.

Yes

Yes

Have a degenera ve lumbar spondylolisthesis, with a slip ≥ 3 mm verified on standing plain x-rays in lateral view.

No

Yes

No

Not responding to at least three months of nonsurgical treatment.

Yes

Yes

Yes

Radiological findings corresponding to the clinical symptoms of LSS. Yes Central-stenosis, or lateral recess-stenosis.

Yes

Yes

Have ODI-score ≥ 25 points.

Yes

Yes

No

Are able to give informed consent and to answer the ques onnaires.

Yes

Yes

Yes

Are over 18 years of age.

Yes

Yes

Yes

Are able to understand Norwegian language, spoken and in wri ng. Yes

Yes

Yes

Exclusion criteria for the NORDSTEN-trial:

SST-arm

DST-arm

OC-arm

Have a degenera ve lumbar spondylolisthesis, with a slip ≥ 3 mm verified on standing plain x-rays in lateral view.

Yes

No

No

Are not willing to give wri en consent.

Yes

Yes

Yes

Have former surgery in the level of stenosis.

Yes

Yes

Yes

Have a fracture or former fusion of the thoracolumbal region.

Yes

Yes

Yes

Have cauda equina syndrome (bowel or bladder dysfunc on) or fixed complete motor deficit.

Yes

Yes

Yes

Are ASA-classified 4 or 5.

Yes

Yes

Yes

Are older than 80 years.

Yes

Yes

Yes

Have a lumbosacral scoliosis more than 20 degrees verified on AP-view.

Yes

Yes

Yes

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Annual report 2015

Have dis nct symptoms in one or both of their legs due to other diseases, e.g., polynevropathy, vascular claudica on or osteoarthri s.

Yes

Yes

Yes

Have LSS in 4 or more levels.

Yes

Yes

Yes

Are not able to comply fully with the protocol, including treatment, follow-up or study procedures (psychosocially, mentally or physically).

Yes

Yes

Yes

Are par cipa ng in another clinical trial that may interfere with this trial.

Yes

Yes

Yes

Current status: AHUS became a member of the study in January 2015. We have currently included 17 pa ents all together. On a na onal scale, we reached the halfway point of included pa ents at the end of December, which means that both the Spinal Stenosis study, with 75 included pa ents, and the Spondylolisthesis study, with 50 pa ents, are the largest randomized study ever worldwide. Project Plan/Timeline: Both the SST-arm and the DST-arm follow almost the same meline. However, there are some differences, and these are accounted for in the brackets. SST-arm:

PreoperaƟvely

3 mth

1 year

2 year

5 year

10 year

PROM-ques onnaires

Yes

Yes

Yes

Yes

Yes

Yes

MRI with measurements of area

Yes

Yes

Standing x-ray of LS-columna with ex/flex

Yes

Yes Yes

Yes

Yes

Yes (SPOgroup)

CT-scan of the operated segment

DST-arm:

PreoperaƟvely

3 mth

1 year

2 year

5 year

10 year

PROM-ques onnaires

Yes

Yes

Yes

Yes

Yes

Yes

MRI

Yes

Standing x-ray of LS-columna with ex/flex

Yes

Yes

Yes

Yes

Yes

Yes (DFgroup)

CT-scan of the operated segment

21

Annual report 2015

2 year

5 year

10 year

Yes

Yes

Yes

Yes

MRI with measurements of area

Yes

Yes

Yes

Yes

Standing x-ray of LS-columna with ex/flex

Yes

Yes

Yes

Yes

OC-arm:

PreoperaƟvely

PROM-quesƟonnaires

3 mth

1 year

PublicaƟons: As of today we have two doctoral students assigned to the project, financed from the Liaison CommiƩee between the Central Norway Regional Health Authority (RHA) and University of Bergen. One doctoral student has responsibility for the LSS-arm, and the other has responsibility for the LDS-arm. We anƟcipate two addiƟonal PhD degrees and one is planned to arise from AHUS. There have been some incenƟves for the Radiology Department to iniƟate a radiological project on data from the study. Funding: Up unƟl now, we have received funding for 7.5 million Norwegian Kroner from the Liaison CommiƩee between the Central Norway Regional Health Authority (RHA) and the Norwegian University of Science and Technology (NTNU). We have two doctoral students involved in the project financed by the Liaison CommiƩee between the Central Norway Regional Health Authority (RHA) and University of Bergen. There will be numerous publicaƟons from the trial that will be sent for publicaƟon in reputable internaƟonal journals. We will also present our research both at naƟonal and internaƟonal spinal congresses.

Spinalstenosis verified on standing plain x-rays in lateral view.

22

Annual report 2015

Upper extremity OperaƟve evaluaƟon of fractures of the middle third of the clavicle. Project group: Main Researcher: Hendrik Frølich Stange Fuglesang, MD, Akershus University Hospital Supervisors: Gunnar B. Flugsrud, MD, PhD, Oslo University Hospital and Stein E Utvåg, MD, Amanuensis, Akershus University Hospital and University of Oslo IntroducƟon: Clavicle fractures are one of the most common fractures, accoun ng for about 4% of all fractures and about 35% of all fractures in the shoulder region. Midsha fractures account for approximately 80% of the clavicle fractures. Tradi onally, midsha fractures have been thought to have a good prognosis even when substan ally displaced, and most have been treated nonopera vely with a sling or a figure-eight bandage. Early studies by Neer and Rowe in the 1960s demonstrated a very low nonunion rate, with a prevalence of 4 in a series of 566 pa ents, and 3 nonunions of 2,235 in another. On this basis, the general view has been that the vast majority of even severely displaced midsha fractures healed uneven ully, with a very low nonunion rate and a good func onal result. Opera ve treatment reported, on the other hand, bad results, especially concerning the risk of infec on. Recent studies, however, draw different conclusions and suggest conserva ve treatment of displaced fractures might not be as favorable as once thought. In a series of 52 completely displaced midclavicular fractures, Hill showed there was a nonunion rate of 15% (8 of 52 pa ents) and 31% rate (16 of 52) of dissa sfac on by pa ents with the end result. This correlated with a shortening of more than 2 cm. In a prospec ve study of 222 pa ents by Nowak, 42% (93 of 222) were found to have persis ng symptoms a er six months, whereas 15% were found to have nonunion. These symptoms seem to persist even a er nine to ten years, at which point 29% of 208 pa ents reported pain during ac vity and 9% pain at rest. Forty-six percent did not consider themselves fully recovered. It is becoming more evident that conserva ve treatment gives significantly inferior results compared to earlier reported results. Opera ve treatment of displaced midclavicular fractures, on the other hand, shows reliably good results compared to earlier reported results. In 2007, the Canadian Orthopaedic Trauma Society published a prospec ve randomized controlled trial of 132 pa ents, randomized to either conserva ve treatment with a sling or plate fixa on. The opera ve group showed clear superiority in Constant and DASH Scores, reduc on in risk of developing nonunion and earlier return to work. With intramedullary nailing using ESIN technique, Smekal et al. demonstrated superior results in the opera ve group in a prospec ve randomized controlled trial of 60 pa ents. Thirty pa ents were operated on with elas c stable intramedullary nailing, and another 30 pa ents were randomized to conserva ve treatment with a sling. The opera ve group had fewer complica ons, shorter me to union and a be er func onal outcome. It seems from the above, that it is reasonable to offer opera ve treatment to ac ve adults with displaced fractures of the middle third of the clavicle due to the risk of developing a symptoma c non- or malunion. Both plate fixa on and intramedullary nailing of displaced fractures are described as safe methods of opera ve treatment. Aim: We aim to conduct a retrospec ve cohort study of conserva vely treated clavicle fractures in the period 2005–2008 in AHUS´catchment area (Study 1). Further, we will conduct a prospec ve randomized controlled study to compare intramedullary nailing and plate fixa on (Study 2) and try to iden fy a treatment algorithm. A five-year follow-up of Study 2 will be health economy evaluated. Materials and methods: Study 1. Retrospec ve cohort study of 59 pa ents. Interview, pa ent-oriented scores (DASH and Constant Score) and radiographic evalua on. Study 2. Prospec ve RCT of 123 pa ents. Randomized to plate or elas c intramedullary nailing. Follow-up at 6, 12, 26, 52 weeks. Radiographic and func onal (DASH and Constant Score) evalua on. SF-36. Study 3. Prospec ve RCT of 123 pa ents, five-year follow-up. Implant survival and health economy evalua on.

23

Annual report 2015 Current status: Study 1. Published. Study 2. Completed. Manuscript in prepara on. Study 3. Pa ents will be interviewed a er a mean of five years, February 2016. PublicaƟons: Fuglesang HF, Flugsrud GB, Randsborg PH, Stavem K, Utvag SE (2015). Radiological and func onal outcomes 2.7 years following conserva vely treated completely displaced midsha clavicle fractures. Arch Orthop Trauma Surg. Funding: Ahus, Internal Strategical Funding, 2016: Ahus, Orthopaedic Clinic Publica on Funding, 2015: Sophies Minde AS: Ahus, Internal Strategical Funding, 2010:

150 000 NOK 10 000 NOK 280 000 NOK 180 000 NOK

Dupuytren’s disease study: A randomized controlled trial comparing clostridium histolyƟcum with needle aponeurotomy. Project group: Main researcher: Ingi Thor Hauksson, MD, Akershus University Hospital Supervisor: Per-Henrik Randsborg, MD, PhD, Akershus University Hospital Clinical coworker: Morten Havdal, MD, Akershus University Hospital StaƟsƟcal coworker: Sigurd Erik. Hoelsbrekken, MD, PhD, Akershus University Hospital and Oslo University Hospital IntroducƟon: Open surgery (fasciectomy) has tradi onally been considered the gold standard of treatment for Dupuytren´s disease (Dd) despite the considerable risk of complica ons. The average recurrence rates are about 40% for fasciectomy and 60% for fasciotomy a er four years. There is an increasing interest in Scandinavia in the treatment of Dd with Clostridium Histoly cum (Xiapex®, Auxillium). The enzyme treatment may provide fewer complica ons and shorter sick leaves. However, the enzyme is expensive and long-term effects are not well documented. More studies are needed to analyze both short- and long-term clinical outcomes as well as cost-benefit analysis. Another treatment of Dupuytren’s contracture is aponeurotomy, a safe and inexpensive method by which the cord is severed with a needle. These two nonopera ve methods have not been compared in a properly designed RCT trial. This is of importance since both treatments may provide be er and more cost-effec ve treatment compared to open surgery. Moreover, serious complica ons rates may be lower. The two procedures leave li le scar ssue, lessening the challenges posed by reopera ons. The recurrence rate of contracture following different treatments of Dupuytren’s disease differs widely in the literature, and the rate is influenced by mul ple factors. Aim: Clinical RCT comparing func onal results and recurrence rate following enzyma c treatment versus needle aponeurotomy. Materials and methods: A contracture of 30° or more in only one metacarpophalangeal (MCP) joint contracture of one of the three ulnar digits and less than 20° for the adjacent proximal interphalangeal (PIP) joint. Pa ents with primary disease of the hand. Total of 80 pa ents needed to detect difference of 13.5°. 1) Needle aponeurotomy. 2) Clostridium Histoly cum treatment. Clinical follow-ups 1 week, 4 weeks, 16 weeks and 1 year, 2 years and 5 years. Func onal outcome scores: URAM, QuickDASH, EQ5D, brief MHQ, VAS pain and VAS pa ent sa sfac on. Total passive extension contracture reduc on, recurrence rate and registra on of complica ons. 24

Annual report 2015

PaƟent with Dupuytren’s contracture treated with Xiepex injecƟon. Foto: Nina Weldingh/Ingi Thor Hauksson

PaƟent with Dupuytren’s contracture on both hands. Before and aŌer treatment with Xiapex injecƟon on the one hand and is aponeurotomy on the other hand. Foto: Ingi Thor Hauksson

Current status: From the start of the study in October 2013 unƟl December 2015, 58 paƟents have been included and treated in the study. Twenty-four paƟents have been included and treated this year. The study is expected to finish inclusion in 2016. PublicaƟons: Haugstvedt, J.R., Hauksson, I.T., Valen, K. and Kvernmo, H.D. Dupuytren´s disease: Clinical features. In David Warwick (eds.),.Dupuytren´s disease: FESSH InstrucƟonal Course 2015.;C.G. EdiƟoni Medico ScienƟfiche Torino; pages 65–73; 2015. Funding: Ahus Internal Strategical Research Grant, 2012: Ahus, Orthopaedic Clinic PublicaƟon Funding, 2015: Sophies Minde Orthopedi AS, 2014: Ahus, Orthopaedic Clinic PublicaƟon Funding, 2015:

220 000 NOK 38 000 NOK 350 000 NOK 20 000 NOK

25

Annual report 2015 PaƟent-reported outcomes in paƟents with proximal humeral fractures, operated with Philos-plate at Ahus 01.01.11–31.12.14. Project group: Main researcher: Sjur Oppebøen, MD, Akershus University Hospital Supervisor: Per-Henrik Randsborg, MD PhD, Akershus University Hospital Research group: AnneƩe K.B. Wikerøy, MD, Akershus University Hospital; Hendrik F. Fuglesang, MD, PhD student, Akershus University Hospital IntroducƟon: Proximal humeral fractures represent the third most common fracture type among the elderly, and the incidence is increasing, although adjus ng for age. An increasing number of the pa ents are treated with surgery, but there is li le evidence that this is necessary. Several studies show li le or no difference between opera ve and nonopera ve treatments, but the studies are small and with selected pa ents, so the results may be a consequence of this. At Ahus we operate on about 60 pa ents with proximal humeral fractures every year. With this study, we want to evaluate our opera onal treatment for these pa ents. Aim: We want to calculate the pa ent-reported outcomes in pa ents with proximal humeral fractures, operated on with Philos-plate over a four-year period. We will also look at which subgroups of pa ents are doing be er/ worse and compare our results with similar treatment in the literature. The inten on is that the study will have implica ons for how these pa ents are treated in the future. Materials and methods: Search and review in Dips shows that the selec on is about 200 pa ents. The validated ques onnaire, Oxford Shoulder Score (OSS), will be the primary outcome. Secondary outcomes consist of complica ons such as infec ons and fixa on failure. Current status: Collec ng data. PublicaƟons: The results will be presented at the Orthopedic Autumn Congress 2016 and published as an ar cle in an orthopedic journal. Funding: Ahus, Orthopaedic Clinic Publica on Funding, 2015:

4 000 NOK

“Radius C-study”—Volar locked plaƟng versus bridging external fixaƟon. Project group: Main Researcher: Ola-Lars Hammer, MD, PhD student, Akershus University Hospital Supervisor: Jan Erik Madsen, MD, Prof. and Consultant in Orthopaedic Surgery Research group: Ståle Clementsen, MD, Akershus University Hospital IntroducƟon: Earlier, the standard method of fixa on of the most comminuted distal radius fractures was an external fixa on supplemented by K-wires. Since the development of the volar locking plate technology, a new approach to the the treatment of these fractures has gained popularity worldwide. Over the past couple of years, the volar locking plate has achieved dominance in the treatment of most fractures of the distal radius. This has occurred without the backing of large prospec ve, randomized studies. There is to date li le solid scien fic data to support this dras c change in treatment ra onale. External fixa on and volar locking plates differ widely in opera ve technique, dura on of immobiliza on postopera vely and poten al complica ons. The newer implants are also significantly more expensive than the established op on of external fixa on. 26

Annual report 2015 Aim:

1) We hope to disclose the various benefits and possible drawbacks of volar locked pla ng versus

augmented external fixa on and hopefully make a recommenda on for a treatment ra onale. 2) A secondary aim of our study is to thoroughly examine the cost of volar locked pla ng versus augmented external fixa on. Materials and methods: We have designed a randomized, prospec ve study for comparison of volar locked pla ng versus Hoffman II bridging external fixa on supplemented by K-wire fixa on in pa ents with comminuted distal radius fractures, AO/OTA type C2 and C3. On the basis of power analysis, a total of 166 pa ents are to be included in this project. The follow-up period is two years and evalua on is based on x-ray analysis, grip strength, range of movement, pain and various tools to measure quality of life and sa sfac on with the treatment (EQ-5d, SF36, QuickDASH). Current status: By February 2015, two-year follow-up of all pa ents was concluded. The remaining year was spent preparing the database and entering a substan al amount of data. The first publica ons are planned for submission by the la er part of 2016. PublicaƟons: None so far. Once the data has been processed, at least two ar cles will be published. Funding: Over the years we have received strategic funds from Akershus University Hospital.

“The MobilizaƟon Study”—The value of early mobilizaƟon and physiotherapy following wrist fractures treated by volar plaƟng. Project group: Main Researcher: Ola-Lars Hammer, MD, PhD candidate, Akershus University Hospital Supervisor: Jan Erik Madsen, MD, Professor and Consultant in Orthopaedic Surgery, Oslo University Hospital Research group: Ståle Clementsen, MD; Joakim Hast, OccupaƟonal Therapist, Akershus University Hospital IntroducƟon: At Akershus University Hospital, the standard regimen following surgery with volar locking plates a er wrist fractures is immobiliza on in a cast for two days and then non-weight-bearing home exercises for the next six weeks. At other hospitals a longer course of post-opera ve immobiliza on is standard prac ce, most o en a cast for two to three weeks. The use of physiotherapy in the postopera ve phase also varies, and the use of physiotherapy at our hospital is most o en le to the individual surgeon, whereas at other facili es it is part of the standard follow-up regimen. There is no solid scien fic data suppor ng a preference for either late or early mobiliza on following a distal radius fracture. Although the idea of early movement seems appealing and desired, the benefits of this have yet to be proven by objec ve measures. On the other hand, no harmful effects have been demonstrated by non-weight-bearing exercises. The use of physiotherapy is widespread, but again the benefits are not measurable in the long term. Aim:

1) We hope to disclose the various benefits and possible drawbacks of early mobiliza on, weight bearing

exercises and physiotherapy versus late mobiliza on and home exercises alone and hopefully make a recommenda on for a postopera ve treatment ra onale. 2) A secondary aim of our study is to examine the cost-benefit of the two possible postopera ve regimens.

27

Annual report 2015 Materials and methods: We have designed a randomized, prospecƟve study for comparison of early mobilizaƟon and physiotherapy versus late mobilizaƟon and home exercises following surgery with a volar locking plate for AO/OTA type A extra-arƟcular fractures. On the basis of power analysis, a total of 124 paƟents are to be included in this project. The follow-up period is two years and evaluaƟon is based on x-ray analysis, grip strength, range of movement, pain and various tools to measure quality of life and paƟent saƟsfacƟon with the treatment (EQ5d, QuickDASH). Current status: Complete follow-up of all paƟents is scheduled to be done by April 2016. We will then start entering the data into the database and planning our publicaƟons. PublicaƟons: None so far. Once the data has been collected and processed, at least two arƟcles will be published. Funding: None.

“The senior study”—Long-term outcome aŌer distal radius fractures in elderly paƟents. Project group: Main Researcher: Ståle Clementsen, MD, Akershus University Hospital Supervisor: Per Henrik Randsborg, MD, PhD, Akershus University Hospital Research group: Ola-Lars Hammer, MD, PhD student, Akershus University Hospital IntroducƟon: The intenƟon is to study the outcome aŌer a distal radius fracture amongst the oldest paƟents. We intend to examine paƟents above the age of 70 who in 2012 sustained a distal radius fracture and were treated at our facility. This includes both well-funcƟoning and low-demand elderly paƟents. We will invesƟgate the type of treatment given and measure outcomes such as mobility, grip strength, pain, QuickDASH-score and x-ray findings. We will also, using instruments such as the VES-13 score, invesƟgate their general level of funcƟoning and view this from the perspecƟve of the other outcome measures. Current status: Data collecƟon is started and will be finished by the end of the spring, data sorƟng and analysis will be finished in the first half of 2016. PublicaƟons: PublicaƟon expected by the second half of 2016. Funding: This project was awarded NOK 345,000 in research funds.

Current management of radius fractures viewed in perspecƟve of paƟent complaints forwarded to The Norwegian System of PaƟent Injury CompensaƟon. Project group: Main Researcher: Erik Engebretsen, MD, Akershus University Hospital Supervisor: Per Henrik Randsborg, MD, PhD, Akershus University Hospital Research group: Ola-Lars Hammer, MD, PhD student, Akershus University Hospital IntroducƟon: A review of all paƟent complaint claims forwarded to The Norwegian System of PaƟent Injury CompensaƟon (NPE) from 2000 through 2013 aŌer treatment for distal radius fractures (ICD-10 S52.5). 28

Annual report 2015 Aim: IdenƟfy the most common causes for compensaƟon granted due to paƟents’ complaints following treatment of distal radial fractures in Norway. Both surgically- and nonsurgically-treated fractures are included in the analysis. The main purpose of the study is to find pearls and piƞalls in how to avoid complicaƟons when treaƟng fractures of the distal radius. A second aim is to esƟmate whether rate or type of complaints have changed during the decade when surgical treatment shiŌed from mainly percutaneous pinning and external fixaƟon to volar locking plates. Lastly, the study will provide a consideraƟon of what is considered acceptable in terms of poor outcome/complicaƟons following treatment of distal radius fractures, as viewed by The Norwegian Ministry of Health and Care. Materials and methods: Data collected from NPE (n=800) will be analyzed for type of fracture, type of iniƟal (primary) treatment, type of complaint, reason for granted compensaƟon and reason for rejected claims. Current status: Data collecƟon finished. Currently undergoing data sorƟng and analysis. PublicaƟons: PublicaƟon expected by 2017. Funding: No funding.

Review of distal radius fractures treated at Akershus University Hospital between 2007 and 2013. Project group: Main Researcher: Erik Engebretsen, MD, Akershus University Hospital Supervisor: Per Henrik Randsborg, MD, PhD, Akershus University Hospital Research group: Ola-Lars Hammer, MD, PhD student, Akershus University Hospital IntroducƟon: A review of all paƟents treated at Akershus University Hospital (Ahus) for a distal radius fracture (ICD-10 S52.5) between 2007 and 2013. Aim: Mapping the epidemiology, incidence and treatment modaliƟes of distal radius fractures in Norway’s largest acute medical hospital. Materials and methods: ProspecƟve collecƟon of data from the Wrist Fracture Register, including diagnosis, fracture classificaƟon, treatment, radiological findings, complicaƟons and number of follow-ups. Current status: Data collecƟon finished. Database established. Currently organizing data electronically. Aim for analysis in first half 2017. PublicaƟons: PublicaƟons expected by 2018. Funding: No funding.

29

Annual report 2015 Lower extremity Focal ArƟcular CarƟlage Lesions of the Knee: Aspects on treatment and prognosis. Project group: Primary researcher: Svend Ulstein, MD, PhD student, Akershus University Hospital Supervisors: Jan H RøƩerud, MD, PhD, Akershus University Hospital; Asbjørn Årøen Professor, MD, Akershus University Hospital; Einar Sivertsen, MD, Deakoness Hospital, Oslo Research group: Lars Engebretsen Professor, MD, Oslo University Hospital/Oslo Sports Trauma Research Center Study 1 Microfracture technique versus osteochondral autologous transplantaƟon mosaicplasty in paƟents with arƟcular chondral lesions of the knee. A prospecƟve randomized trial with long-term follow-up. Study 2 PaƟent-reported outcome following ACL reconstrucƟon in paƟents with and without a concomitant full-thickness carƟlage lesion. A prospecƟve cohort study with five- to nine-year follow-up. Study 3 The reliability of the InternaƟonal CarƟlage Repair Society (ICRS) classificaƟon system for grading chondral lesions of the knee arthroscopically. Study 4 Outcome following ACL reconstrucƟon in knees with concomitant carƟlage lesions: A naƟonwide cohort study from Sweden and Norway with five-year follow-up. Study 5 Anterior Cruciate Ligament reconstrucƟon and concomitant focal carƟlage lesions: Prognosis and treatment; a systemaƟc review.

Study 1 Microfracture technique versus osteochondral autologous transplantaƟon mosaicplasty in paƟents with arƟcular chondral lesions of the knee. A prospecƟve randomized trial with long-term follow-up. Project group: Main researcher: Svend Ulstein, MD, PhD candidate, Akershus University Hospital Supervisor: Asbjørn Årøen, Prof. MD, Akershus University Hospital Research group: Jan Harald RøƩerud, MD, Akershus University Hospital; Sverre Løken, MD, Oslo University Hospital Lars Engebretsen, Prof. MD, Oslo University Hospital Oslo Sports Trauma Research Center; SƟg Heir, MD, PhD, MarƟna Hansens Hospital IntroducƟon: There is liƩle knowledge regarding the long-term outcome aŌer carƟlage surgery. Aim: To compare long-term funcƟonal and radiological outcome following microfracture technique (MF) versus osteochondral autologous transplantaƟon (OAT) mosaicplasty for treaƟng focal chondral lesions of the knee. Materials and Methods: Twenty-five paƟents (mean age 32.3 years, SD 7.7) with a full-thickness (InternaƟonal CarƟlage Repair Society grade 3 or 4) chondral lesion of the arƟculaƟng surface of the femur were randomized to either MF (n=11) or OAT mosaicplasty (n=14). At a median follow-up of 9.8 years (range 4.9-11.4) the paƟents were evaluated using the Lysholm score (n=25), Knee Injury and OsteoarthriƟs Outcome Score (KOOS, n=25), isokineƟc quadricepsand hamstring strength measurements (n=22) and standing radiographs (n=23). 30

Annual report 2015 Results: There were no significant differences in Lysholm score, KOOS, isokine c muscle strength or radiographic osteoarthri s between MF-treated pa ents and OAT mosaicplasty-treated pa ents at follow-up. The mean Lysholm score at follow-up was 69.7 (95% confidence interval [CI], 55.1-84.4) for the MF-group and 62.6 (95% CI, 52.6-72.6) for the OAT mosaicplasty group. Current Status: Published 2014 Oral presenta ons at ISAKOS/Toronto 2013, ESSKA/Amsterdam 2014, Oslo Sports Trauma Research Center Spring Seminar 2014 and 2015, Annual Mee ng of the Norwegian Orthopaedic Associa on 2013. Funding Ahus Internal Strategical Research Grant, 2013: Sophies Minde Orthopedi AS, 2013:

150,000 NOK 79,500 NOK

PublicaƟons: Ulstein S, Aroen A, RoƩerud JH, Loken S, Engebretsen L, Heir S. Microfracture technique versus osteochondral autologous transplantaƟon mosaicplasty in paƟents with arƟcular chondral lesions of the knee: a prospecƟve randomized trial with long-term follow-up. Knee Surg Sports Traumatol Arthrosc. (2014) Study 2 PaƟent-reported outcome following ACL reconstrucƟon in paƟents with and without a concomitant full-thickness carƟlage lesion. A prospecƟve cohort study with five- to nine-year follow-up. Project group: Main researcher: Svend Ulstein, MD, PhD student, Akershus University Hospital Supervisor: Asbjørn Årøen, Prof. MD, Akershus University Hospital Research group: Karin Bredland, PT, M.Sc., Oslo University Hospital; Lars Engebretsen, Prof. MD, Oslo University Hospital and Oslo Sports Trauma Research Center; Jan Harald RøƩerud, MD, PhD, Akershus University Hospital Aim: To compare pa ent-reported outcome five to nine years a er anterior cruciate ligament (ACL) reconstruc on in pa ents with and without a concomitant full-thickness (Interna onal Car lage Repair Society [ICRS] grade 3-4) car lage lesion. Material and Methods: This is a prospec ve follow-up of a cohort of pa ents that were iden fied in the Norwegian Na onal Knee Ligament Registry and included in the current study in 2007, consis ng of 30 primary ACL-reconstructed pa ents with a concomitant, isolated full-thickness car lage lesion (ICRS grade 3 and 4) and 59 matched controls without car lage lesions (ICRS grade 1–4). At a median follow-up of 6.3 years (range, 4.9–9.1) a er ACL reconstruc on, 74 (84%) pa ents completed the Knee Injury and Osteoarthri s Outcome Score (KOOS), which was used as the main outcome measure. Secondary outcomes included radiographic evalua on according to the Kellgren-Lawrence criteria of knee osteoarthri s (OA). Results: At follow-up, five to nine years a er ACL reconstruc on, no sta s cally significant differences in KOOS were detected between pa ents with a concomitant full-thickness car lage lesion and pa ents without concomitant car lage lesions. Radiographic knee OA of the affected knee, defined as Kellgren and Lawrence ≥ 2, was found significantly more frequently in subjects without a concomitant car lage lesion (P = .016). Conclusions: ACL reconstruc on performed in pa ents with a concomitant full-thickness car lage lesion restored pa entreported knee func on to the same level as ACL-reconstruc on performed in pa ents without concomitant car lage lesions, five to nine years a er surgery. Level of evidence: Prognos c; prospec ve cohort study, Level I. 31

Annual report 2015 Current Status;

Submi ed KSSTA. Oral presenta ons at Oslo Sports Trauma Research Center Spring Seminar, 2015 and Annual mee ng of the Norwegian Orthopaedic Associa on 2014. Funding Ahus Internal Strategical Research Grant, 2014: Ahus, Orthopaedic Clinic Publica on Funding, 2015:

250 000 NOK 6 500 NOK

The development of a naƟonal knee carƟlage defect register. Project group: Main researcher: Cathrine Nørstad Engen, 50% PhD student at Oslo Sports Trauma Research Center, Norwegian School of Sports Sciences, and 50% at Skadelegevakten, Akershus University Hospital Supervisors: Asbjørn Årøen, Professor, Akershus University Hospital; Lars Engebretsen, Professor, Department of Orthopaedic Surgery, Oslo University Hospital and Faculty of Medicine, University of Oslo; Co-chair, Oslo Sports Trauma Research Center; Head Scien fic Ac vi es, Interna onal Olympic Commi ee (IOC) Current status: The PhD project aims to develop a register for pa ents with focal car lage defects (FCDs) of the knee. There are s ll research gaps in regard to treatment and long-term prognosis from these defects, both when operated and nonoperated. High-quality RCTs can fill some, however not all, gaps. A long-term prospec ve clinical study that includes these pa ents would answer important ques ons concerning prognos c factors a er both conserva ve treatment and car lage repair. In addi on, the effec veness of the different treatment modali es will be outlined. Before establishing a knee car lage defect register (hereby car lage register), the incidence of car lage surgery should be assessed. We have also performed a methodological study looking at the external validity of RCTs within car lage repair. The long-term effect of FCDs was assessed with dGEMRIC. Finally, we will perform a pilot study of the car lage register. Funding: The project was ini ated through the Medical Student Research Program at the University of Oslo and funding was obtained through this program. Since the end of March 2014, the project has been funded through grants from the Oslo Sports Trauma Research Center at the Norwegian School of Sports Sciences. We received Aase Bye og Trygve J. B. Hoffs fond, 2014: Ahus, Orthopaedic Clinic Publica on Funding, 2015:

15 334 NOK 31 500 NOK

1. Incidence of Knee Car lage Surgery in Norway, 2008–11 Engen, Årøen, Engebretsen IntroducƟon: A systema c and long-term data collec on on the treatment of focal car lage defects (FCDs) of the knee is needed. This can be achieved through the founda on of a Na onal Knee Car lage Defect Registry. The aim of this study was to establish the na onwide burden of knee car lage surgery, defined as knee surgery in pa ents with an FCD. We also aimed to iden fy any geographical differences in incidence rates, pa ent demographics or trends within this type of surgery. Material and methods: Se ng: Popula on-based study with retrospec ve iden fica on of pa ents undergoing knee car lage surgery in Norway through a mandatory public health database from 2008–11. Par cipants: We iden fied all pa ents undergoing car lage surgery or other knee surgery in pa ents with an FCD. All eligible surgeries were assessed for inclusion based on certain types of ICD-10 and NCSP codes. 32

Annual report 2015 Primary and secondary outcome measures: The variables were diagnos c and surgical codes, geographic loca on of the performing hospital, age and sex of the pa ents. Yearly incidence and incidence rates were calculated. Age-adjusted incidences for risk ra os and odds between geographical areas were also calculated. Results: A total of 10,830 cases of knee car lage surgery were iden fied, with slight, although significant decreases from 2008–11 (p