www.ahus.no

Annual Report 2018

Academic Activities

Department of Orthopaedic Surgery

www.ahus.no

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CONTENTS

CONTENTS

ORTHOPAEDIC RESEARCH GROUP

THE RESEARCH YEAR 2018 IN REVIEW

ORTHOPAEDIC RESEARCH COMMITTEE 2018

Summary of Research Activity

ORTHOPAEDIC SYMPOSIUM

PRIZES AND AWARDS

ONGOING RESEARCH PROJECTS

Fractures in children

Upper extremity

Lower extremity

Spinal injuries

MEDICAL STUDENT PROJECTS

PUBLICATIONS

Publications (peer reviewed)

Commentaries

Abstracts

PRESENTATIONS

Invited lectures

Other lectures

Arranged seminars/meetings

Academic assignments

MEDIA

RESEARCH FUNDING 2018

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ORTHOPAEDIC RESEARCH GROUP

Research Fellows: Asbjørn Årøen (Professor) Stein Erik Utvåg (Associate Professor) Truls M. Straume-Næsheim (Postdoc) Per-Henrik Randsborg (Postdoc) Jan Harald Røtterud (PhD) Aron Adelved (PhD) Rune Bruhn Jakobsen (PhD) Oliver Grundnes (PhD) Inge Skråmm (PhD) Christian Owesen (PhD) Cathrine Nørstad Engen (PhD) Ola-Lars Hammer (PhD student) Svend Ulstein (PhD student) Ingi Thor Hauksson (PhD student) Stefan Bartels (PhD student) Hendrik Fuglesang (PhD student) Filip C. Dolatowski (PhD student) Ståle Myhrvold (PhD student) Ståle Clementsen (PhD student) Christian Pollmann (PhD student) Annette Wikerøy (PhD student) Espen Femmo Brouwer Stian Kjennvold Max Temmesfeld Monica Sailer Sjur Oppebøen Jakob Vangen Nordbø Sverre Mjønes Heidi A. Hanvold (study coordinator) Eline Elshaug Schjønneberg (study nurse) Torunn Hammer (study nurse) Tine Karlsrud Pettersen (study nurse) Sofie Høen (study nurse) Therese Vårheim Gundersen (study nurse) Trine Fjeld Myhrvold (study nurse) Kathrine Wang (medical student) Thomas Alexander Øverby (medical student) Archana Ananthaharan (medical student) Magnus Aanstad (medical student)

Head: Professor Asbjørn Årøen

Research positions and PhD students

University employees: Professor II Asbjørn Årøen Associate Professor Stein Erik Utvåg D-positions: Svend Ulstein – ligament and cartilage injuries Christian Pollmann – hip fractures 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 University candidate with a teaching duty of 30% Guri Ekås – knee ligaments

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THE RESEARCH YEAR 2018 IN REVIEW Closing the Gap: 2018 in review The Orthopaedic Research Group at Akershus University Hospital has as one of its goals to be among the major academic orthopedic centers in Nordic countries. As there are several strong research groups in neighboring countries, this is clearly an ambitious aim. Another issue is how to measure our performance as a team. The research administration has now initiated an evaluation of the research groups at our hospital, and this process will produce valuable feedback that we can use in 2019 to further increase our achievements together. Our publication rate is steadily increasing, and the number of PhD staff members in our department is growing as planned, with at least one new PhD member added annually. We also have hopes for at least two more staff members in 2019. However, our publications outside the PhD program need to be increased in order to reach our aim of approximately 30 publications annually. This is definitely a challenge, considering the high level of motivation required to undertake the work involved. As long as researchers are in the PhD program, there is strong internal motivation to produce manuscripts to complete their defense. Our long-term colleague, Anders Wensaas, completed his PhD this fall. We are happy to express our sincere congratulations to him for his achievements in exploring the difficult clinical problems regarding the hip and slipped capital femoral epiphysis. Grant achievements have not been as successful as warranted. However, both Kjennvold and Wikerøy were granted funding by Sophie Minde in 2018, which provided much needed support to their projects on important clinical topics. We strongly hope that 2019 will see extended support provided to many of our important projects. We definitely need to improve this field, which has been an area of focus in recent years, but competition is increasing, especially from nonuniversity hospitals. The hospital research unit has improved its grant writing support, which will probably be an important tool for making progress in this area. Finally, I would put forward that we are in a position to close the gap that exists between our ambitions and the actual status of our group. I wish all of you a productive upcoming research year in 2019, and I want to remind you that each person’s contribution is an important one for continuing progress in our field of research. Best regards, Professor Asbjørn Årøen

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ORTHOPAEDIC RESEARCH COMMITTEE 2018

Head Associate Professor Section Chief of Knee and Hip Fractures Dept. of S205 Orthopaedic Nursing, Head Dept. of Orthopaedic Surgery, Physician Dept. of Orthopaedic Surgery, Physician Dept. of Orthopaedic Surgery, Physician Research Coordinator

Asbjørn Årøen Stein Erik Utvåg Stefan Bartels Wenche Bjerkestrand Jacobsen Truls M. Straume-Næsheim Per-Henrik Randsborg Rune Bruhn Jakobsen Nina Mickelson Weldingh

Orthopaedic Research Committee Left to right: Wenche Bjerkestrand Jacobsen, Asbjørn Årøen, Truls Martin Straume-Næsheim, Rune Bruhn Jacobsen, Stefan Bartels, Per-Henrik Randsborg. Not present on the day of photography: Stein-Erik Utvåg Photo: Nina M Weldingh The principal tasks of the committee are as follows:

• Promote research and research training for all workers in the Orthopaedic Clinic • Develop research activities, research quality, and publication frequency within the

Orthopaedic Research Group • Improve the communication of orthopedic research and published results from the

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

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Summary of Research Activity Peer-reviewed publications and dissertations of members of the Department of Orthopaedic Surgery in the last nine years.

02468

1012141618

2010 2011 2012 2013 2014 2015 2016 2017 2018Publications 4 5 6 12 9 8 13 17 17Dissertations 0 1 1 1 0 2 0 2 0

Peer-reviewed publications and dissertations 2010-2018

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ORTHOPAEDIC SYMPOSIUM

Injuries of the upper extremity The Department of Orthopaedic Surgery Research Day Akershus University Hospital, October 12th, 2018 This year's theme for the external research seminar was injuries of the upper extremity. The seminar was fully booked, which empathizes the importance of procuring a larger auditorium for the next seminar. The seminar is very popular among physiotherapists, who as a group are among our key partners. We are also working to attract more general practitioners at these seminars. This is the third year we have applied for and received approval from the Norwegian Medical Association as an optional course for physicians in specialization and for specialist postgraduate education. The Orthopaedic Clinic has several different ongoing research projects covering injuries in the upper extremities, and we invited our internal lecturers and PhD candidates to present the research areas included within the Orthopaedic Research Group, Ahus. The lectures dealt with both clavicle fractures, radius fractures, olecranon fractures, humerus fractures and shoulder lesions, as well as damage to the upper limbs of children. The Researcher and Senior Consultant at Lovisenberg Diaconal Hospital was invited as an external lecturer in the treatment of SLAP injuries. The lessons dealt with both surgery, conservative treatment and rope rehabilitation. The feedback and evaluations from the seminar have been very positive, and we want to continue our annual external seminars, with a new orthopedic topic every year.

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PRIZES AND AWARDS Orthopaedic Research Group Best Paper Award 2017: Fuglesang HFS, Utvåg SE, Flugsrud GB, Randsborg P-H, Oord P, Benth JS. “Plate fixation versus intramedullary nailing of completely displaced midshaft fractures of the clavicle”. Bone Joint J 2017;99-B:1095–1101

Left to right: Hendrik Fuglesang, Asbjørn Årøen

Research Stipend Smith and Nephew’s arthroscopy stipend 2018 Monica Sailer received Smith and Nephew’s arthroscopy stipend for the study; "Predictors for infection after surgical reconstruction of the anterior cruciate ligament of the knee" during the Arthroscopic Association's winter meeting on February 3.

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MEDICAL STUDENT THESIS

Thomas Øverby Title: Infections after routine syndesmotic screw removal – a retrospective quality study. Main supervisor: Rune Bruhn Jakobsen Throughout his project, Thomas has found that the infection rate after removal of a sinusmoscrew is low. However, when infection occurs, surgical revision and long-term antibiotic

treatment are often required. Providing prophylactic antibiotics can reduce the risk of infection, but probably not to a degree justifying the increased use of broad-spectrum antibiotics.

Magnus Aanstad Title: The forecast for full return after surgical reconstruction of the frontal gangway in athletes to the same level as before rupture appears to be worse than previously assumed. Main supervisor: Asbjørn Årøen Throughout his project, Magnus found that the forecast for full return after surgical reconstruction of the forearm ribbons to the same level of sports as before rupture was measured at 42%, which is much lower than the previously given 65% forecast. Furthermore, it is seen that women are much

underrepresented among the selection of participants in research on rupture of the front cross bands. Magnus concludes that quality records such as the National Crossroads Register should have a validated scoring system that evaluates sports levels both before surgery and after completion of rehabilitation. He believes this approach is particularly important since,

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to many athletes, the main purpose of undergoing surgery after such injury is to provide knee stability that would enable a return to the sport, which in many cases caused the injury.

Håkon Solvang and Robin Nordheggen Title: En epidemiologisk studie av distale radiusfrakturer Supervisors: Ola-Lars Hammer and Per-Henrik Randsborg

Solvang and Nordheggen found a lower incidence of distal radius fractures in their study than in previous reports from Norway, which they believe may be due to a decrease in the number of violations. Postmenopausal women had a higher risk of fractures than the other groups, and low-energy injuries were most dominant. A total of 26.7% of patients were treated operatively, which was higher than the percentage in previous reports. Solvang and Nordheggen believe this finding may reflect a trend towards increased operational treatment.

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ONGOING RESEARCH PROJECTS

Upper extremity Operative evaluation of fractures of the middle third of the clavicle. Hendrik Frølich Stange Fuglesang MD PhD student, Gunnar B Flugsrud MD PhD (Oslo University Hospital) and Stein Erik Utvåg MD PhD. Part 1: Functional outcome after conservative and operative treatment of midshaft clavicle fractures.

A fracture of the clavicle is a common occurrence in both children and adults and usually occurs in the middle third of the shaft. While these fractures have traditionally been treated conservatively with a sling, a recent growth of interest has led to more fractures being managed operatively, although strong evidence for this approach is lacking. Papers I and II in this thesis aim to assess the patient-reported outcomes after nonoperative treatment of midshaft clavicle fractures in adolescents and adults to evaluate to what extent the fracture affects the patient´s shoulder function after several years. The first paper in this thesis finds that good to excellent functional outcomes are to be expected after nonoperative treatment after clavicle fractures in 10- to 18-year-old patients, whereas the second paper focuses only on adults with displaced fractures. Most adult patients have a favorable outcome, but approximately 25% have functional deficits after treatment with a sling. However, as more patients are being surgically treated, what is the optimal method of fracture fixation? We randomized 123 adult patients with completely displaced midshaft clavicle fractures to either plate fixation (PF) or elastic stabile intramedullary nailing (ESIN) (papers III and IV). After one year, there was no difference between the methods, and most patients returned to their preinjury shoulder function. In fractures with comminution, PF provided a faster return of shoulder function than ESIN. Approximately half of the ESIN patients were treated with closed reduction, and this group had a better functional outcome in the first six months but also had less pain after 5 years compared to the group receiving open ESIN and PF. This result suggests that if the fracture does not lend itself to closed reduction and ESIN, the

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surgeon should convert to PF. Approximately 1/3 of the plates were removed during the first five years, mostly due to pain over the implant, compared to 2/3 of the nails. Part 2: Functional outcome after conservative and operative treatment of midshaft clavicle fractures. Introduction: Clavicle fractures are one of the most common fractures, accounting for approximately 4% of all fractures and approximately 35% of all fractures in the shoulder region. Midshaft fractures account for approximately 80% of the clavicle fractures. Traditionally, midshaft fractures have been thought to have a good prognosis even when substantially displaced, and most have been treated nonoperatively 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 nonunions in a series of 566 patients and 3 nonunions in another series of 2,235 patients. On this basis, the general view has been that the vast majority of even severely displaced midshaft fractures heal uneventfully, with a very low nonunion rate and a good functional result. Operative treatment was reported to yield poor results, especially concerning the risk of infection. Recent studies, however, draw different conclusions and suggest that conservative treatment of displaced fractures might not be as favorable as once thought. In a series of 52 completely displaced midclavicular fractures, Hill showed a nonunion rate of 15% (8 of 52 patients) and a 31% rate (16 of 52) of patient dissatisfaction with the end result. This outcome was correlated with a shortening of more than 2 cm. In a prospective study of 222 patients by Nowak, 42% (93 of 222) were found to have persistent symptoms after six months, whereas 15% were found to have nonunion. These symptoms seemed to persist even after nine to ten years, at which point 29% of 208 patients reported pain during activity and 9% reported pain at rest. Forty-six percent of the patients did not consider themselves fully recovered. Therefore, it is becoming more evident that conservative treatment gives significantly inferior results compared to earlier reported results. Operative treatment of displaced midclavicular fractures, on the other hand, shows reliably good results compared to earlier reported findings. In 2007, the Canadian Orthopaedic Trauma Society published a prospective randomized controlled trial of 132 patients randomized to either conservative treatment with a sling or PF. The operative group showed clear superiority in Constant and DASH Scores, reduction in the risk of developing nonunion and earlier return to work. With intramedullary nailing using the ESIN technique, Smekal et al. demonstrated superior results in the operative group in a prospective randomized controlled trial of 60 patients. Thirty patients were operated on with elastic stable intramedullary nailing, and another 30 patients were randomized to conservative treatment with a sling. The operative group had fewer complications, a shorter time to union and a better functional outcome.

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It seems from the abovementioned results that it is reasonable to offer operative treatment to active adults with displaced fractures of the middle third of the clavicle due to the risk of developing a symptomatic nonunion or malunion. Both PF and intramedullary nailing of displaced fractures are described as safe methods of operative treatment. Aim: We aim to conduct a retrospective cohort study of conservatively treated clavicle fractures in the period 2005–2008 in the Ahus catchment area (Study 1). Furthermore, we will conduct a prospective randomized controlled study to compare intramedullary nailing and PF (Study 2) and try to identify a treatment algorithm. A five-year follow-up of Study 2 will be reported in Paper 3. Materials and methods: Study 1. Retrospective cohort study of 59 patients. Interview, patient-oriented scores (DASH and Constant Score) and radiographic evaluation. Study 2. Prospective randomized controlled trial (RCT) of 123 patients. Randomized to plate or elastic intramedullary nailing. Follow-up at 6, 12, 26, and 52 weeks. Radiographic and functional (DASH and Constant Score) evaluation. SF-36. Study 3. Prospective RCT of 123 patients, five-year follow-up. Current status: All studies have been published. Hendrik FS Fuglesang successfully defended the thesis on April 11, 2019. Funding: Ahus Internal Strategical Research Funding 2016 150 000 NOK Ahus Department of Orthopaedic Surgery Publication Funding 2015 10 000 NOK Sophie’s Minde Orthopedic AS Grant 2013 280 000 NOK Ahus Internal Strategical Research Funding 2010 180 000 NOK Total Funding: 620 000 NOK Calcar screws and adequate reduction reduces the risk of fixation failure in proximal humeral fractures treated with a locking plate: 190 patients followed for a mean of 3 years. Sjur Oppebøen MD, Annette K. B. Wikerøy MD PhD student, Hendrik F. S. Fuglesang MD PhD student, Filip C. Dolatowski MD PhD student, Per-Henrik Randsborg MD PhD Introduction: Fixation of proximal humeral fractures (PHFs) with locking plates has gained popularity over conservative treatment, but surgery may be complicated with infection, nonunion, avascular necrosis (AVN) of the humeral head, and fixation failure. Failure to achieve structural support of the medial column has been suggested to be an important risk factor for fixation failure. The aims of this study were to examine the effect of calcar screws and fracture reduction on the risk of fixation failure and to assess long-term shoulder pain and function. Patients and methods: This was a retrospective study of 190 adult PHF patients treated with a locking plate during 2011–2014. Reoperations due to fixation failure were the primary

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outcome. Risk factors for fixation failure were assessed using a Cox regression analysis. Postoperative shoulder pain and function were assessed by the Oxford Shoulder Score (OSS). Results: Thirty-one of 190 (16%) patients underwent reoperation: 14 (7%) due to fixation failure, 10 (5%) due to deep infection and 2 (1%) due to AVN. The absence of calcar screws and fixation with residual varus malalignment (head-shaft angle <120°) both increased the risk of fixation failure with an adjusted hazard ratio (95% CI) of 8.6 (1.9-39.3; p = 0.005) and 4.6 (1.3-16.8; p = 0.02), respectively. The median (interquartile range) OSS was 40 (27-46). Conclusion: The use of calcar screws, as well as the absence of postoperative varus malalignment, significantly reduced the risk of fixation failure. Long-term shoulder function following locking plate fixation was good. Current status: Review in the journal Injury. Funding: Ahus, Orthopedic Clinic Publication Funding, 2015 4 000 NOK Plate fixation versus intramedullary nailing of 3- and 4-part proximal humerus fractures. A prospective, double blinded randomized controlled trial. Annette K.B. Wikerøy MD PhD student, Per Henrik Randsborg MD PhD, Hendrik S.F. Fuglesang MD PhD student, Rune Brun Jakobsen MD PhD Introduction: The population is aging, and the incidence of proximal humerus fractures (PHFs) is increasing. New angle-stable implants provide better stability for complex osteoporotic fractures; thus, more fractures are treated surgically. The most common complications are related to the osteosynthesis material: varus failure (4-14%) or penetration of screws through the cartilage in the shoulder joint. The most common implant used in Norway is the locking stable plate, but many other countries use locking stable nails. The two methods seem to have comparable functional results; there may be a slightly higher complication rate in the plates. Both implants require adequate reduction; they provide fixation options for stabilizing the tuberosities and the calcar.

The nails may add additional stability, hindering varus failure when introduced flush or just below the cartilage surface. The locking plate may stabilize the tuberosities more rigidly and provides more angle-stable screws in the humeral head to prevent osteosynthesis failure. We wish to conduct a prospective randomized controlled trial to compare nail versus plate fixation in 3- and 4-part PHFs. These two well-established methods have not been compared in a level-one manner.

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Aim: The project’s aim is to compare the operative treatment of 3- and 4-part fractures of the shoulder with angle-stable plates or nails in light of clinical and radiological results over 2 years. The project is part of Dr. Wikerøy’s planned PhD. Primary aim: Functional outcome of surgical treatment as evaluated by the DASH score at follow-up. Secondary aims: Registration of radiological complications defined by a reduction in head-shaft angle (HSA) of ≥10⁰ in the frontal plane or screw penetration/cut-out, screw failure or failure of the osteosynthesis on radiographs within two years. Initial radiographic examination performed with standardized radiograph projections; true anteroposterior projection and scapula projection pre- and postoperatively. Computer tomographic (CT) scans before and after surgery will help clarify the classification, fracture configuration and results. The HSA varies between 120-140⁰ in the normal population, so we will take front radiographs of the opposite proximal humerus of all included patients to act as their own control. Functional outcome of surgical treatment as evaluated by the Constant score by independent and blinded physiotherapists during follow-up. Measurement of strength performed according to recommendations given by the European Society of Shoulder and Elbow Surgeons ESSSE (http://secec.org/). EQ-5D, a generic measure of health status that provides a simple descriptive profile used in the clinical evaluation of health care. Health economic registration will include information on length of hospital stay, sick leave, use of physiotherapy, appointments at general practitioners, extra treatments at an in-patient orthopedic clinic, removal of the plate or nail, extra surgeries, implant costs, and operating theater time. We will monitor complications such as deep or superficial infection, avascular necrosis, nerve or vessel damage and DVTs. We will also invite patients to attend a 5-year and a 10-year follow-up appointment. During these late controls, all the primary and secondary outcomes will be as described above. Materials and methods: This is a single-centered randomized controlled trial (RCT). Patients admitted to Ahus from 01.10.16 to 01.10.19 with a displaced 3- or 4-part proximal humeral fracture of OTA/ AO group 11B2 or 11C2 in need of surgical treatment will be randomly allocated to two groups: intramedullary nailing or angular stable plate fixation. Inclusion criteria:

1. Patients > 18 years 2. Severe displacement, defined as malposition of at least 45⁰ of angular deviation in

valgus or 30⁰ in varus in the true frontal projection, regardless of whether the fracture is impacted

3. >=50 angular deviation in Y-projections 4. Fractures with more than 50% displacement of the head against the surgical neck 5. The greater or lesser tubercles must be fractured in a 3- or 4-part fracture. The

degree of displacement must be >= 5 mm.

Exclusion criteria: 1. Fracture more than 3 weeks old 2. Caput humeri that is just a thin shell or split 3. Ipsilateral damage that will influence the recovery and scoring systems 4. Incapability to protect osteosynthesis, i.e., use of crutches because of injury to the

lower extremity 5. Pathological fracture 6. Neurovascular injury

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7. Open fracture 8. Noncompliance 9. Congenital anomaly 10. Ongoing infectious process around the incision site for plate osteosynthesis 11. Systemic disease that may influence the healing processes or scoring systems

(RA/MS) 12. Fracture dislocation 13. Substance abuse 14. Inability to read and understand Norwegian 15. Patients not residing in our catchment area 16. Patients with a humerus diameter that is too small for use of a nail

Statistical power: A change in subscore of 10 on the DASH score is considered clinically significant (Hunsaker). Therefore, for power analysis, a difference in change of 10 between two treatment groups is assumed. A standard deviation of the DASH score is assumed to be 15 for each method as suggested by Hunsaker (24). With a significance level of 5% and power of 80%, usual power calculations suggest a sample of 36 patients treated by each method of operation, that is, a total sample of 72. We aim to include 90 patients to allow for a risk of losing 20% of patients to follow-up. We treated 142 patients surgically for 3- and 4-part PHF over 4 years (2011-2014). We estimate the inclusion time to be approximately 2.5-3 years. Status: Since starting patient enrollment in this RCT on October 5, 2016, we have enrolled 38 subjects. This number is lower than expected, but no unexpected events have occurred. Postoperative CT scans of included patients accepted by REK have been added. A phantom for measuring bone density in these CT examinations has also been added; this analysis is being performed in cooperation with Dr. Hasan Banitalebi (Radiology Department). Funding: 2017 Strategiske midler Ahus 150 000 NOK 2016 Norsk ortopedisk forenings forskningsstipend 50 000 NOK 2016 Smith and Nephew’s forskningsstipend 25 000 NOK 2017 Forskningsmidler, Sofies Minde AS 389 000 NOK 2017 Open Access forskningskomiteen orto avd 20 000 NOK 2018 Sofies Minde AS 349 725 NOK 2018 Ahus Strategiske midler 217 500 NOK Total Funding: 1 196 225 NOK

Intramedullary nailing of a PHF

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“Radius C-study” -Volar locked plating versus bridging external fixation Ola-Lars Hammer MD PhD student, Jan Erik Madsen MD PhD (Oslo University Hospital), Ståle Clementsen MD PhD student, Per-Henrik Randsborg MD PhD.

Introduction: Previously, the standard method of fixation of the most comminuted distal radius fractures was an external fixation supplemented by K-wires. Since the development of volar locking plate technology, a new approach to the treatment of these fractures has gained popularity worldwide. Over the past few 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 prospective, randomized studies. There is to date little solid scientific evidence to support this drastic change in treatment rationale. External fixation and volar locking plates differ widely in operative technique, postoperative duration of immobilization and potential complications. The newer implants are also significantly more expensive than the established option of external fixation. Aim: 1. We hope to disclose the various benefits and possible drawbacks of volar locked plating versus augmented external fixation and to recommend a treatment rationale. 2. A secondary aim of our study is to thoroughly examine the cost of volar locked plating versus augmented external fixation. Materials and methods: We designed a randomized, prospective study for comparison of volar locked plating versus Hoffman II bridging external fixation supplemented by K-wire fixation in patients with comminuted distal radius fractures, AO/OTA type C2 and C3. On the basis of power analysis, a total of 166 patients are to be included in this project. The follow-up period is two years, and evaluation is based on X-ray analysis, grip strength, range of movement, pain and various tools to measure quality of life and satisfaction with the treatment (EQ-5d, SF-36, QuickDASH). Current status: By February 2015, a two-year follow-up of all patients was concluded. The authors spent 2016 finishing the database, entering a substantial amount of data and performing the statistical analysis. During 2017/2018, the first publication was completed and submitted, and the two remaining publications were drafted. Publications: The first publication is confirmed for publication in the February 2019 edition of the Journal of Bone and Joint Surgery (JBJS). The second article will be submitted mid-February to The Bone & Joint Journal, and the third will most likely be ready for submission in April 2019. The article titles are as follows:

Plate fixation of a proximal humerus fracture

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1. Volar Locking Plates Versus Augmented External Fixation in Intra-articular Distal Radius Fractures - A Randomized, Controlled Study Functional Outcome

2. The Cost-effectiveness of a Volar Locking Plate Compared to Augmented External Fixation In Displaced Intra-articular Wrist Fractures

3. Does Generic Patient-Rated Outcome Measurements Reflect the Function of the Upper Extremity Following Surgical Treatment of a Wrist Fracture?

Funding: Ahus Internal Strategical Research Funding 2015 100 000 NOK Ahus Internal Strategical Research Funding 2011 100 000 NOK Total Funding: 200 000 NOK “The senior study” - Long-term outcome after distal radius fractures in elderly patients Ståle Clementsen MD PhD student, Per Henrik Randsborg MD PhD, Ola Lars Hammer MD PhD student. Introduction: The intention is to study the outcome after a distal radius fracture amongst the oldest patients. We intend to examine patients, above the age of 70, who in 2012 sustained a distal radius fracture and were treated at our facility. This includes both well-functioning and low-demand elderly patients. We will investigate the type of treatment given and measure outcomes such as mobility, grip strength, pain, Quick-DASH-score and x-ray findings. We will also, using instruments such as the VES-13 score investigate their general level of functioning and view this in the perspective of the other outcome measures. Current status: Data collection is almost complete, and will be finished by the end of spring 2018, data sorting and analysis during summer 2018. Publications: Submission is expected by the end of 2018 Funding: Sophies Minde Ortopedi AS Grant 2014 345 000 NOK “The Mobilization Study” - The value of early mobilization and physiotherapy following wrist fractures treated by volar plating. Ståle Clementsen MD PhD student, Per Henrik Randsborg MD PhD, Ola Lars Hammer MD PhD student. Introduction: At Akershus University Hospital the standard regimen following surgery with volar locking plates after wrist fractures is immobilization in a cast for 2 days and then non-weight-bearing home exercises for the next 6 weeks. At other hospitals, a longer course of post-operative immobilization is standard practice, most often a cast for 2-3 weeks. The use of physiotherapy in the post-operative phase also varies, and the use of physiotherapy at our hospital is most often left to the individual surgeon, whereas it at other facilities is part of the standard follow-up regimen.

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There is no solid scientific data supporting a preference for neither late nor early mobilization following a distal radius fracture. Although the idea of early movement seems appealing and wanted, the benefits of this have yet to be proven by objective measures. On the other side, no harmful effect has 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 mobilization, weight-bearing exercises and physiotherapy versus late mobilization and home exercises alone and hopefully make a recommendation for a postoperative treatment rationale.

2. A secondary aim for our study is to examine the cost-benefit of the two possible postoperative regimens.

3. Materials and methods: We have designed a randomized, prospective study for comparison of early mobilization and physiotherapy versus late mobilization and home exercises following surgery with a volar locking plate for AO/OTA type A extra-articular fractures. On the basis of power analysis, a total of 124 patients are to be included in this project. The follow-up period is two years and evaluation is based on x-ray analysis, grip strength, range of movement, pain and various tools to measure quality of life and patient satisfaction with the treatment (EQ-5d, QuickDASH). Current status: Complete follow-up of all patients was concluded in April 2016. These are now being entered into the database. Publications: The first submission is expected by the first half 2019. Funding: None. Current management of radius fractures viewed from the perspective of patient complaints forwarded to The Norwegian System of Patient Injury Compensation. Ståle Clementsen MD, Per Henrik Randsborg MD PhD, Erik Engebretsen MD, Ola-Lars Hammer MD PhD student. Introduction: A review of all patient complaint claims forwarded to The Norwegian System of Patient Injury Compensation (NPE) from 2000 through 2013 after treatment for distal radius fractures (ICD-10 S52.5) was conducted. Aim: Identify the most common causes for compensation granted due to patients’ 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 pitfalls regarding how to avoid complications when treating fractures of the distal radius. A second aim is to estimate whether the rate or type of complaints changed during the decade when surgical treatment shifted from mainly percutaneous pinning and external fixation to volar locking plates. Last, the study will provide a consideration of what is considered acceptable in terms of poor outcome/complications following treatment of distal radius fractures, as viewed by The Norwegian Ministry of Health and Care.

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Materials and methods: Data collected from NPE (n=800) will be analyzed for type of fracture, type of initial (primary) treatment, type of complaint, reason for granted compensation and reason for rejected claims. Current status: The study is completed, and the manuscript is currently under review in a peer-reviewed international orthopedic journal. Publication is expected in 2018. Funding: No funding. Review of distal radius fractures treated at Akershus University Hospital between 2007 and 2013. Ola-Lars Hammer MD PhD student, Per Henrik Randsborg MD PhD, Erik Engebretsen MD Håkon With Solvang MD stud, Robin Nordheggen MD stud. Introduction: A review of all patients 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 modalities of distal radius fractures in Norway’s largest acute medical hospital. Materials and methods: Prospective collection of data from the Wrist Fracture Register, including diagnosis, fracture classification, treatment, radiological findings, complications and number of follow-ups. Current status: The study is completed and submission is expected in first half of 2019 Funding: No funding. Dupytren’s disease study: A randomized controlled trial comparing Clostridium histolyticum with needle aponeurotomy. Ingi Thor Hauksson MD PhD student, Per-Henrik Randsborg MD PhD, Morten Havdal MD, Sigurd E Hoelsbrekken MD PhD. Introduction: Open surgery (fasciectomy) has traditionally been considered the gold standard of treatment for Dupuytren´s disease (Dd) despite the considerable risk of complications. The average recurrence rates are approximately forty percent for fasciectomy and sixty percent for fasciotomy after four years. In Scandinavia, there is increasing interest in the treatment of Dd with Clostridium histolyticum (Xiapex ®, Auxillium). Enzyme treatment may provide fewer complications 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 to perform a 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 nonoperative methods have not been compared in a properly designed RCT trial. This is of importance since both treatments may provide better and more cost-effective results compared to open surgery. Moreover, the rates of serious complications may be lower. The two procedures leave little scar tissue, lessening the challenges posed by the reoperations. The recurrence rate of

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contracture following different treatments of Dupuytren’s disease differs widely in the literature, and the rate is influenced by multiple factors. Aim: Clinical RCT comparing the functional results and recurrence rate following enzymatic treatment versus needle aponeurotomy. Materials and methods: Inclusion criteria were as follows: 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 and patients with primary disease of the hand. A total of 80 patients were needed to detect a difference of 13.5°. 1) Needle aponeurotomy 2) Clostridium histolyticum treatment Clinical follow-ups: 1 week, 4 weeks, 16 weeks, 1 year, 2 years and 5 years. Functional outcome scores: URAM, QuickDASH, EQ5D, brief MHQ, VAS pain and VAS patient satisfaction. Total passive extension contracture reduction, recurrence rate and registration of complications. Current status: From the start of the study in October 2013 through December 2017, 80 patients were included and treated. Follow-ups are being continuously performed. All patients have been followed for 2 years. Ingi Thor Hauksson plans to use the results of this study as the main project for his PhD thesis. Per-Henrik Randsborg is a supervisor. The first paper is being drafted. Funding: Ahus Internal Strategical Research Funding (2012) 220 000 NOK Ahus Department of Orthopaedic Surgery Publication Funding (2015) 38 000 NOK Sophie’s Minde Orthopaedic AS Grant (2014) 350 000 NOK Ahus Department of Orthopaedic Surgery Publication Funding (2015) 20 000 NOK Total funding: 628 000 NOK

Lower extremity Screw fixation versus hemiarthroplasty for undisplaced femoral neck fractures in elderly patients: a multicenter randomized controlled trial Filip C. Dolatowski, MD PhD student, Frede Frihagen MD PhD, Stefan Bartels, MD, Vidar Opland, MD (Bærum Hospital, Vestre Viken Hospital Trust), Jūratė Šaltytė Benth PhD, Ove Talsnes MD PhD (Elverum Hospital, Innlandet Hospital Trust), Sigurd Erik Hoelsbrekken MD PhD (LHL Hospital Gardermoen) and Stein Erik Utvåg MD PhD. Background: Elderly patients with a displaced femoral neck fracture treated with hip arthroplasty may have better function than those treated with internal fixation. We hypothesized that hemiarthroplasty would be superior to screw fixation with regard to hip function, mobility, pain, quality of life, and the risk of reoperation in elderly patients with a nondisplaced femoral neck fracture. Methods: In a multicenter randomized controlled trial (RCT), Norwegian patients ≥70 years of age with a nondisplaced femoral neck fracture were allocated to screw fixation or hemiarthroplasty. Assessors blinded to the type of treatment evaluated the hip function with the Harris hip score (HHS) as the primary outcome as well as on the basis of mobility

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assessed with the timed “Up & Go” (TUG) test, pain as assessed on a numerical rating scale, and quality of life as assessed with the EuroQol-5 Dimension-3 Level (EQ-5D) at 3, 12, and 24 months postsurgery. The results, including reoperations, were assessed with an intention-to-treat analysis. Results: Between February 6, 2012, and February 6, 2015, 111 patients were allocated to screw fixation and 108 to hemiarthroplasty. At the time of follow-up, there was no significant difference in hip function between the screw fixation and hemiarthroplasty groups, with a 24-month HHS (and standard deviation) of 74 ± 19 and 76 ± 17, respectively, and an adjusted mean difference of −2 (95% confidence interval [CI] = −6 to 3; p = 0.499). Patients allocated to hemiarthroplasty were more mobile than those allocated to screw fixation (24-month TUG = 16.6 ± 9.5 versus 20.4 ± 12.8 seconds; adjusted mean difference = 6.2 seconds [95% CI = 1.9 to 10.5 seconds]; p = 0.004). Furthermore, screw fixation was a risk factor for major reoperation, which was performed in 20% (22) of 110 patients who underwent screw fixation versus 5% (5) of 108 who underwent hemiarthroplasty (relative risk reduction [RRR] = 3.3 [95% CI = 0.7 to 10.0]; number needed to harm [NNH] = 6.5; p = 0.002). The 24-month mortality rate was 36% (40 of 111) for patients allocated to internal fixation and 26% (28 of 108) for those allocated to hemiarthroplasty (RRR = 0.4 [95% CI = −0.1 to 1.1]; p = 0.11). Two patients were lost to follow-up. Conclusions: In this multicenter RCT, hemiarthroplasty was not found to be superior to screw fixation in re-establishing hip function as measured by the HHS (the primary outcome). However, hemiarthroplasty led to improved mobility and fewer major reoperations. The findings suggest that certain elderly patients with a nondisplaced femoral neck fracture may benefit from being treated with a latest-generation hemiarthroplasty rather than screw fixation. Publication current status: Accepted during September 2018, by The Journal of Bone and Joint Surgery. Fast-track hip fracture—an optimized patient pathway for hip fracture patients. Christian Pollmann MD PhD student, Johan Halse MD, Stefan Bartels MD, Truls Straume-Næsheim MD PhD, Jan-Harald Røtterud MD PhD, Olav Lenvik, Fredrik Dahl, Jan Erik Gjertsen MD PhD (Haukeland University Hospital), Asbjørn Årøen, MD PhD. Introduction: Elderly patients with hip fractures have a 30-day mortality rate of up to 11%, and a one-year mortality rate of over 30% has been reported. In addition, the injury causes significant morbidity, and only approximately 60% of the patients return to their prefall level of functional independence. Orthopedic research has mainly focused on operative techniques with little impact on morbidity and mortality. A fast-track patient pathway with a focus on multimodal pain relief, stress reduction, early mobilization and nutrition constitutes a more holistic approach to the treatment of hip fracture patients and should be suited to benefit this frail group of patients. Aim: To elucidate the impact of a fast-track pathway for hip fracture patients on mortality. Materials and methods: Mortality, rates of reoperation and surgical site infections are compared for a patient cohort before and after introduction of a fast-track pathway for hip fracture patients.

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Current status: Database completed; 1 manuscript submitted. Publications: A manuscript was submitted to BMC Musculoskeletal Disorders on October 2, 2018. Funding: Sophie’s Minde AS, 2014: 225 000 NOK Heraeus Medical, 2014: 50 000 NOK Total Funding: 275 000 NOK Debridement, antibiotics and implant retention (DAIR) for infected total hip arthroplasty- does the operative approach influence the functional result? Christian Pollmann MD, Asbjørn Årøen MD PhD, Geir Hallan, MD PhD (Haukeland University Hospital), Håvard Dale MD PhD (Haukeland University Hospital), Eva Hansen Dybvik PhD, Jan Erik Gjertsen MD PhD (Haukeland University Hospital). Introduction: Infection after total hip arthroplasty is a dreaded complication. Debridement, antibiotics and implant retention (DAIR) has been shown to have a good success rate in early infections with stable implants and better functional results than two-stage revisions. In patients where infection control was achieved with just one DAIR procedure, the functional result was comparable to those of uncomplicated primary hip arthroplasties. However, it is not known whether the operative approach during the primary operation and the DAIR procedure influence this functional result. Aim: The project’s aim is to investigate whether the operative approach (transgluteal or posterior approach) to the hip joint under primary arthroplasty and the revision procedure have an influence on the functional result after DAIR for infected arthroplasty of the hip. Materials and methods: All patients who have been operated once with a DAIR procedure and where the same operative approach has been used during the primary and the revision procedure will be identified in the Norwegian Arthroplasty Register. These patients will be contacted by mail and will be asked to complete three questionnaires. The answers from the questionnaires and the data from the Norwegian Arthroplasty Register will be used in a multiple regression analysis to determine if there is a difference in the outcome measures between the groups. The main outcome measure will be the function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Current status: Questionnaires have been sent to all potential participants. The response rate was 52%. All nonrespondents will be contacted again. Funding: Ortomedic AS, 2016 100 000 NOK Molecular and imaging biomarkers in delirium and dementia Leiv Otto Watne, MD PhD (Oslo University Hospital), Christian Pollmann MD PhD student, Asbjørn Årøen MD PhD, Torunn Hammer, Eline Elshaug Schjønneberg, Tine Karlsrud Pettersen, Sofie Høen, Linda Andresen.

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Introduction: Delirium is characterized by sudden impairment in awareness and cognition and is a common complication of acute somatic illness in the elderly. There is evidence that delirium can precipitate dementia in patients who were previously cognitively intact and accelerate deterioration in those who already are demented. However, the pathophysiology of delirium is still poorly understood. Hip fracture patients are well suited to study delirium. On the one hand, this frail patient group is at a high risk of developing delirium. On the other hand, the majority of hip fracture patients are administered spinal anesthesia, which facilitates the procuration of cerebrospinal fluid. In contrast to blood, cerebrospinal fluid is in close contact with the brain’s neurons. The analysis of cerebrospinal fluid can therefore provide important information on the pathophysiologic mechanisms in the brain that lead to delirium. Aim: To elucidate pathophysiologic mechanisms in delirium. Materials and methods: Prospective observational study. Cerebrospinal fluid and blood samples are collected from hip fracture patients who are administered spinal anesthesia. Patients are assessed for prefracture cognitive status and general health and are followed daily during their hospital stay to detect the development of delirium. Current status: One hundred and two patients have been included in the study. The aim is to include a total of 200 patients. Funding: Nasjonalforeningen for folkehelsen

Treatment and functional outcome in patients younger than 70 years with displaced femoral neck fractures. Stefan Bartels MD PhD student, Stein Erik Utvåg MD PhD, Frede Frihagen PhD, Cecilia Rogmark MD PhD (Skåne University Hospital Malmö and University of Lund), Jan-Erik Gjertsen MD PhD (Haukeland University Hospital, Bergen), Wender Figved MD PhD (Bærum Hospital), Filip Dolatowski MD PhD student, Torbjørn Kristensen MD PhD (Haukeland University Hospital). Introduction: Patients younger than 70 years with a displaced femoral neck are in serious condition. Femoral neck fracture (FNF) is associated with low activity levels, hip pain and substantially reduced quality of life. In this study, we aim to determine whether patients aged 55 - 70 years with displaced and low-energy FNFs treated with total hip arthroplasty (THA) gain better functional outcomes than those undergoing osteosynthesis and whether patient-related factors predispose patients to FNFs. Aim:

1. Map the functional outcome and complications associated with displaced low-energy FNFs in patients under 70 years of age treated in the period January 2005 - December 2012 in Norway.

2. Map patient-related factors that predispose to displaced FNFs for patients aged 55-70 years.

3. Map bone density measured with Dexa for two types of surgical procedures. 4. In a randomized multicenter study, map complications and functional

outcomes after osteosynthesis or THA in patients aged 55 - 70 years with displaced FNF.

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Materials and methods: Part I. In cooperation with the Norwegian Hip Fracture Registry, we published data about treatment methods and functional outcome for patients aged 55 - 70 years with displaced FNFs in the period January 2005 - December 2012. Finished In Part II, 50 patients aged 55 - 70 years with displaced low - energy FNF will be measured with Dexa. The results will be compared with those for an age- and sex-matched normal population (150 persons). Part III is a randomized multicenter study of patients operated on with either total hip replacement (THA) or osteosynthesis (IF) where functional outcome, complications and reoperations are compared for the 2 groups. In progress, submitted to Osteoporosis Int. Dec. 2018 Part IV Treatment and functional outcome in patients under 55 years with displaced femoral neck fracture - An observational study of patients reported to the Norwegian Hip Fracture Register «from January 2005 - December 2017: in progress, data processing in progress» Funding: Strategic research funding Ahus 2014 210 000 NOK Sophie’s Minde Orthopedic AS 2014 670 000 NOK Sophie’s Minde Orthopedic AS 2015 670 000 NOK Strategic research funding (publication) 2013 30 000 NOK Total funding: 1 158 000 NOK Effect of Concomitant Cartilage Lesions on Patient-Reported Outcomes after Anterior Cruciate Ligament Reconstruction: A Nationwide Cohort Study from Norway and Sweden of 8470 Patients with a 5-year Follow-up Svend Ulstein MD PhD student, Asbjørn Årøen MD PhD, Magnus Forssblad (Capio Artro Clinic, Stockholm Sports Trauma Research Center, Karolinska Institutet), Lars Engebretsen MD PhD (Oslo University Hospital), Stein Håkon Låstad Lygre MD (Haukeland University Hospital) og Jan Harald Røtterud MD PhD. Background: The effect of concomitant focal cartilage lesions on patient-reported outcomes after anterior cruciate ligament reconstruction (ACLR) remains to be determined. Purpose: To evaluate the effect of concomitant partial-thickness (International Cartilage Repair Society [ICRS] grades 1-2) and full-thickness (ICRS grades 3-4) cartilage lesions on patient-reported outcomes 5 years after ACLR. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: All patients who underwent unilateral primary ACLR registered in the Norwegian and Swedish National Knee Ligament Registries from 2005 through 2008 (n = 15,783) were included in the study. At the 5-year follow-up, 8470 (54%) patients completed the Knee Injury and Osteoarthritis Outcome Score (KOOS). Linear regression models were used to estimate the effect of concomitant focal cartilage lesions on the patient-reported outcome (KOOS) 5 years after ACLR and to estimate the effect of surgical debridement or MF of concomitant full-thickness cartilage lesions on patient-reported outcome 5 years after ACLR.

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Results: Compared to no concomitant cartilage lesions, both partial-thickness and full-thickness cartilage lesions showed statistically significant adverse effects on all KOOS subscales in the adjusted regression analyses at the 5-year follow-up after ACLR. Compared to no surgical treatment, there were no unadjusted or adjusted effects of debridement or MF of concomitant full-thickness cartilage lesions on the KOOS at the 5-year follow-up. Conclusion: ACL-injured patients with concomitant cartilage lesions reported worse outcomes and less improvement than those without cartilage lesions 5 years after ACLR. Current status: Published OJSM AJSM 2018. Oral presentation at the 2018 Annual Meeting of The American Orthopaedic Society for Sports Medicine. Funding: None. Anterior cruciate ligament reconstruction and concomitant focal cartilage lesions: Prognosis and treatment; a systematic review. Svend Ulstein MD PhD student, Asbjørn Årøen MD PhD, Einar Sivertsen MD (Diakonhjemmet Hospital), Jan Harald Røtterud MD PhD. Introduction: The coincidence of anterior cruciate ligament (ACL) tears and focal articular cartilage damage is common. The current literature is conflicting as to the prognosis and treatment of choice after such combined injury. Aim: To perform a systematic review of the current literature on the prognosis after combined surgical treatment of ACL and focal cartilage injury to support evidence-based clinical decisions and improve patient outcomes. Materials and Methods: A computer-based systematic search (MEDLINE via PubMed, EMBASE via OvidSP, Cochrane Library, Web of Science databases) will be performed to identify all published literature reporting the prognosis and/or treatment of combined ACL-injury and focal cartilage lesions. This will be followed by a systematic review of eligible studies identified in the systematic search by standardized data extraction and quality assessment. If sufficient homogeneity exists (prognosis and/or treatment) in outcome measures across included studies, a meta-analysis will be performed. In the case of considerable heterogeneity, a best-evidence synthesis will be used. Current Status: This project is registered in PROSPERO databases. A systematic search was designed and performed (December 2017), and data are being analyzed in Distiller SR. Funding: Publication Ortopedisk Klinikk kr 12 000 NOK Norwegian Cartilage Project NCP - Microfracture Study Tommy Aae MD PhD (Kristiansund Hospital), Asbjørn Årøen MD PhD, Per-Henrik Randsborg, MD PhD, Heidi Hanvold PT. The NCP is a national multicenter research group instigated by Professor Asbjørn Årøen and led by post doc Per-Henrik Randsborg at Ahus. It includes 8 different hospitals in four health regions of Norway, and the projects include two RCTs, a register study and basic science studies.

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Introduction: Focal cartilage lesions in adults are common and affect young adults. The treatment is difficult, and no current gold standard is established. Microfracture has been recommended for smaller lesions but has never been compared with physiotherapy alone. Aim: The aim is to compare microfracture with arthroscopic debridement and physiotherapy. Materials and methods: Patients aged 18-50 with isolated grade III or IV cartilage lesions of the femoral condyles or trochlea less than 2 cm2 are prospectively randomized to receive either microfracture or arthroscopic debridement. A total of 114 patients will be included in 7 different hospitals (Ahus, Ullevål, Diakonhjemmet, Kristiansund, Ålesund, Haukeland and Haraldsplass). Current status: Recruiting patients. Planned Publications: Microfracture vs debridement of isolated cartilage defects of the knee: a multicenter RCT. The costs of microfracture vs debridement of cartilage defects of the knee in patients aged 18-50 years. Biomarkers for successful cartilage healing after microfracture. Funding: Helseforsk, 19 millioner, 2015 Norwegian Cartilage Project NCP - Autologous Chondrocyte Implantation Study (ACI study). Asbjørn Årøen MD PhD, Per-Henrik Randsborg MD PhD, Heidi Hanvold PT, Jan Brinchmann MD PhD (Rikshospitalet), Lars Engebretsen MD PhD (Ullevål University Hospital) The NCP is a national multicenter research group instigated by Professor Asbjørn Årøen and led by postdoctoral fellow Per-Henrik Randsborg at Ahus. It includes 8 different hospitals in four health regions of Norway, and the projects include two RCTs, a register study and basic science studies. Introduction: Focal cartilage lesions in adults are common and affect young adults. The treatment is difficult, and no current gold standard is established. Autologous chondrocyte implantation (ACI) has been recommended for larger lesions but has never been compared with physiotherapy alone. Aim: The aim is to compare ACI with arthroscopic debridement and physiotherapy. Materials and methods: Patients aged 18-50 with isolated grade III or IV cartilage lesions of the femoral condyles or trochlea larger than 2 cm2 are prospectively randomized to receive either ACI or arthroscopic debridement. A total of 82 patients will be included, and the patients will be treated at Ahus or OUS/Ullevål and followed up at a designated research clinic at Ahus. Current status: Currently recruiting and treating patients. Planned Publications: ACI vs debridement of isolated cartilage defect of the knee: an RCT. The costs of ACI vs debridement of cartilage defects of the knee in patients aged 18-50 years. Biomarkers for successful cartilage healing after ACI.

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Funding: Helseforsk, 19 millioner, 2015

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Knee laxity and patient-reported knee function after two different rehabilitation protocols: one with use of dynamic knee orthosis and a control group with no knee orthosis for patients with acute isolated PCL injuries: A randomized controlled study. Hilde Stømner PT Master, Inge Skråmm MD PhD, Christian Owesen MD, Joakim Hast PT, Rikard Moen PT, Asbjørn Årøen MD PhD, Karin Bredland PT Master (Oslo University Hospital), Ingrid Trøan PT (Oslo University Hospital), Sverre Løken MD PhD (Oslo University Hospital), Marc Strauss MD (Oslo University Hospital), Lars Engebretsen MD PhD (Oslo University Hospital). Introduction: No high-quality evidence or evidence-based guidelines are available regarding bracing/nonbracing or rehabilitation protocols for patients with acute PCL injury treated nonsurgically. Ideal management remains uncertain. Aim: The purpose of the study is to determine whether one rehabilitation/treatment option is preferable to another and examine whether there would be differences in knee laxity and patient-reported knee function after the two different rehabilitation protocols. We aim to determine whether there is a difference in knee laxity measured with PCL stress radiographs in patients with acute isolated PCL injury after rehabilitation with or without the use of dynamic PCL orthosis 3 and 12 months after the injury. Materials and methods: A randomized controlled study of 80 patients with acute isolated PCL injury, with follow-up after three and twelve months. Outcome measures:

• Knee laxity posterior translation by PCL stress radiographs • Knee injury and Osteoarthritis Outcome Score (KOOS) • International Knee Documentation Committee (IKDC) • Knee stability test (single jump)

Current status: Enrollment of patients is ongoing, and 26 patients are included. Publications: None yet Funding: None, last funding in 2016

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Reconstruction of the medial patellofemoral ligament versus conservative treatment of chronic patellar instability: An RCT. Project group: Truls M. Straume-Næsheim MD PhD, Asbjørn Årøen MD PhD, Brian Devitt MD FRCS (MMedSc, OrthoSport Victoria, Melbourne), JE Brand MD (Heartland Orthopaedics, Alexandria, MN), Einar Sivertsen MD PhD (Marna Hansen’s Hospital), Jan Rune Mikaelsen MD. Introduction: Patella dislocation is a serious knee injury whose peak incidence occurs in patients aged 10–17 years and is associated with a high rate of redislocation. Knee injuries frequently cause long-term disability and reduced physical activity among adolescents and young persons. Surgery in this patient group requires a low tolerance for complications, meaning that physical therapy might offer more successful outcomes in many knee injury cases. The proposed project studies a particular patient cohort subjected to recurrent dislocation of the patella. Aim: The principal objective of this clinical, randomized controlled trial (RCT) is to evaluate and compare knee function and symptoms in patients with recurrent patella dislocation randomized into treatment with surgical reconstruction of the medial patellofemoral ligament (MPFL) with those of patients in a standardized physiotherapy program designed to stabilize the patella and improve patient function. Materials and methods: Patients aged 12–30 years who have experienced two or more patella dislocations are randomized into groups receiving either MPFL reconstruction or physical therapy only. Follow-ups at 3, 6, 12, and 36 months involve functional tests, validated knee scores, arthroscopic examination, and cartilage-specific MRI protocols for the knee. Current status: The recruitment of patients has been finalized with a total of 60 patients included. The patients will be followed for three years. The first paper assessing the baseline data has recently been resubmitted. Preliminary 1-year data were presented at the biannual meeting of the European Society for Sports Traumatology, Knee Surgery and Arthroscopy in Glasgow in May 2018. Publication plan: Planned

1. Objective measure of knee function in patients with recurrent patella dislocation. 2. Knee function and activity level in patients with recurrent patella dislocation treated

with MPFL: Reconstruction and active rehabilitation at the two-year follow-up. 3. Knee function and level of activity in patients with recurrent patella dislocation

treated with MPFL reconstruction or active rehabilitation at three-year follow-up: A randomized clinical trial.

4. Patient benefits after knee ligament surgery: Which ligament surgery is most effective? MPFL reconstruction and ACL reconstruction at the three-year follow-up evaluated with knee injury and osteoarthritis outcome scores (KOOSs).

5. MRI assessment of cartilage structure in the patellofemoral joint in a randomized clinical trial of MPFL reconstruction versus more conservative treatment.

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Funding: Sophie’s Minde AS, 2011–2016: 500 000 NOK Aase Bye and Trygve J. B. Hoff’s Fund, 2014: 17 000 NOK The Norwegian Association of Sports Medicine, Research Grant 2015: 50 000 NOK South-Eastern Norway Regional Health Authority, Postdoc grant 2016–2017 per year: 500 000 NOK Overseas grant: 386 000 NOK Total Funding: 1 453 000 NOK

Treatment results after acute Achilles tendon rupture: A randomized controlled trial comparing conservative treatment with open and minimal invasive surgery. Project group: Ståle Myhrvold MD PhD student, Sigurd Erik Hoelsbrekken MD PhD, Lars Engebretsen MD PhD (Oslo University Hospital), Stein Erik Utvåg MD PhD. Research group: Espen Brouwer MD, Madeleine Amundsen MD (Oslo University Hospital) Maren Paus, MD (Oslo University Hospital), Charlotte Ferner Heglund MD (Oslo University Hospital), Faisal Butt MD (Buskerud Hospital), Wolfram Grün MD (Østfold Hospital), Karin Rydevik MSc (NIMI), Kjetil Waal MD (Oslo University Hospital) Introduction: Achilles tendon rupture can be treated operatively or nonoperatively. Since the risk of rerupture after surgery is thought to be lower than after conservative treatment, surgery is considered to be the best treatment, despite the potential for wound complications and nerve damage. However, new rehabilitation regimes have yielded favorable treatment results after nonoperative treatment. Aim: Since no consensus exists regarding the treatment of Achilles tendon ruptures, in this study, we aim to investigate whether one type of treatment is superior. Materials and methods: This randomized controlled trial compares nonoperative treatment with open and minimally invasive surgery. The study is a collaboration among four hospitals and involves 530 patients. Testing is performed blindly at NIMI and Ahus. Different methods of measuring the length of the Achilles tendon have been tested, and a publication of the reliability of three different methods was published in Knee Surgery, Sports Traumatology, and Arthroscopy (KSSTA) in 2017. A validation of the Norwegian versions of the patient-reported outcome measures of the Achilles Tendon Total Rupture Score (ATRS) and Foot and Ankle Outcome Score (FAOS) is also published in KSSTA in 2017. We will also conduct a treatment–cost analysis in relation to individual results. Current status: All 530 patients were included by the end of May 2018. By the end of December 2018, we had performed a 12-month follow-up of 505 patients. All patients were followed for 12 months post-injury. Publications: All testing of patients was completed in June 2019, and the database was then be closed. Analysis of data will continue through late 2019 in conjunction with the Clinical

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Trial Unit at Oslo University Hospital. In 2017, we published both the validation of a method of measuring the length of the Achilles tendon by use of ultrasound (KSST-D-17-00632R3 Ultrasound measurement of Achilles tendon length using skin markings was more reliable than extended-field-of-view imaging) and the Norwegian validation of ATRS (KSST-D-17-00576R2 Validity and reliability of the Norwegian translation of the Achilles tendon Total Rupture Score). The main article will be published in early 2020 together with the health economic study, and the PhD thesis is planned to be completed in early 2020. Funding: Internal Strategic Funding, Ahus, 2013: 250 000 NOK PhD Scholarship from Helse Sør-Øst: 2 750 000 NOK Bye & Hoff’s Fund for Scientific Medical Research, 2014 17 000 NOK Total Funding: 3 017 000 NOK

Spinal injuries The NORDSTEN trial, a randomized multicenter study comparing different surgical procedures in patients with spinal stenosis with or without degenerative slippage. Scientific Board: Christian Hellum MD PhD (Oslo University Hospital), Kjersti Storheim ScD Associate Professor (Oslo University Hospital), FORMI (a Communication and Research Unit in the Division of Neuroscience, Oslo University Hospital), Kari Indrekvam MD Associate Professor (Haukeland University Hospital), Jens Ivar Brox MD Professor (Oslo University Hospital), Oliver Grundnes MD PhD (Akershus University Hospital), Tore Solberg MD Associate Professor (University Hospital of North Norway), Ivar Magne Austevoll MD PhD student (Haukeland University Hospital), Erland Hermansen MD PhD student (Aalesund Hospital) and Frode Rekeland MD (Haukeland University Hospital). Administrative Executive Board: Kari Indrekvam MD Associate Professor Haukeland University Hospital), Berit Kvalsvik Teige PhD (More and Romsdal Health Trust), Kjersti Storheim Associate Professor (Oslo University Hospital), FORMI, Christian Hellum MD PhD (Oslo University Hospital), Erland Hermansen MD PhD student (Aalesund Hospital) and Ivar M Austevoll MD PhD student (Haukeland University Hospital). Working Committee/Participating Hospitals: Leader: Erland Hermansen MD PhD student (Aalesund Hospital). Members: One surgeon and one study coordinator from each participating hospital. Participating hospitals (16): 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, Martina Hansen Hospital, Drammen Hospital, Skien Hospital, Arendal Hospital The three sub-studies each have a project manager: SST: Erland Hermansen MD PhD student (Aalesund Hospital). DST: Ivar Magne Austevoll MD PhD student, (Haukeland University Hospital).

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OC: Frode Rekeland MD (Haukeland University Hospital) Introduction: The trial consists of three different arms:

1. SST-arm: Lumbar Spinal Stenosis arm 2. DST-arm: Lumbar Degenerative Spondylolisthesis arm 3. OC-arm: Observational Cohort

In this trial, we distinguish between Lumbar Spinal Stenosis (LSS) and Lumbar Degenerative Spondylolisthesis (LDS). These two conditions are handled in two separate pathways. We also have an Observational Cohort, consisting of patients that suffer from the LSS radiologically, but do not have sufficient amount of symptoms to justify surgery. 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 quantify the degree of decompression required to maintain the best results. In the LDS-arm, the main issue is whether a fusion in addition to a midline-preserving decompression is needed to maintain the best results. In the Observational Cohort (OC) we want to investigate whether there are characteristics in the symptomatology or radiological findings that can explain why some of the patients have milder clinical symptoms. The number of patients that require surgical treatment at a later stage will be noted. We have received an approval from the Norwegian Committees for Medical and Health Research Ethics (2011/2034 and 2013/366). Aim: The main objective of the study is to find which choice of treatment gives the best clinical results evaluated by Patient 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) after two, five and ten years. In the OC-arm, the primary outcome is time-to-operation or whether the patients 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-questionnaires have been evaluated in several studies. Differences according to surgical methods will also be registered. Complications, operation time, 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. 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 distinction between verified slip or not. Current status: AHUS became a member of the study in January 2015. We have currently included 24 patients in the LSS study and 12 in the LDS. On a national scale, by 07.12.2017 392 patients are included in the LSS study which comprises 84 % of the total number. Respectively 264 patients were included in the LDS group (104 %) and 231 in the OC group. This makes the present study the largest randomized study ever worldwide. One doctoral student has responsibility for the LSS-arm, and the other has responsibility for the LDS-arm.

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We anticipate two additional PhD degrees. MD Jørn Åen, Ålesund Hospital is granted a 6 years scholarship based on a 50 % participation with the title:

“Radiological findings in patients with spinal stenosis before and after surgery: comparing the impact of three surgical techniques

Furthermore, there have been some incentives for the Radiology Department to initiate a radiological project on data from the study and Hassan Banitalebi is now working on a PhD protocol. Project Plan/Timeline: Both the SST-arm and the DST-arm follow almost the same timeline. Inclusion in the DST study is now finished and inclusion in the SST study is planned to end at April 2018. Publications: There will be numerous publications from the trial that will be sent for publication in reputable international journals. We will also present our research both at national and international spinal congresses. Funding: Up until now, we have received funding for 7.5 million Norwegian Kroner from the Liaison Committee 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 Committee between the Central Norway Regional Health Authority (RHA) and University of Bergen.

Nursing Research Factors that may impact the functional level of older patients following hip fracture surgery Marit Kirkevold PhD, Sofie Høen, Study Nurse at Akershus University Hospital; Linda Andresen, Study Nurse at Akershus University Hospital Eline E. Schjønneberg, Study Nurse at Akershus University Hospital, Torunn Hammer, Study Nurse at Akershus University Hospital and Maria Cocozza, Study Nurse at Akershus University Hospital. Introduction: Numbers from the hip fracture register indicate that one year after surgery, only approximately half of patients who were independent in walking, personal hygiene and activities of daily living have regained the same level of functioning (Hoftebruddregisteret 2012). Reduced functional level and high mortality are related to frailty and comorbidity but may additionally be associated with complications following hip fracture. Some of these complications may be prevented or limited by tailored treatment and follow-up (Holvik et al. 2010). The literature review shows that a number of patient-related factors may explain the functional level both before and after a hip fracture in older patients. Several of these factors may be modified by nursing measures in the days prior to and following surgery. One essential goal for the treatment of patients following hip fracture is improved short-term and long-term functioning. Consequently, it is important to assess whether and to what degree these factors are present and impact the outcome. This knowledge will make it

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possible to intervene early and target factors that may contribute to the negative development, thereby preventing at least some of the functional decline. Aim: The main purpose of this project is to contribute knowledge that may improve the nursing care of patients with hip fracture. Specifically, the purpose is to explore which factors impact the level of functioning at discharge and after three months postdischarge. Materials and methods: The study is exploratory and longitudinal. The patients are assessed at admission, every day during hospitalization and after three months. This study plans to utilize parts of the data already being collected for the CSF/delirium study. In addition, we will collect data on nutritional status at admission, daily mobilization status following the surgery, and functional level before admission, at discharge and at 3 months after discharge. Furthermore, pain and nausea are assessed daily, and grip strength is assessed pre- and postoperatively once during hospitalization. In addition, other data assumed to potentially influence the level of functioning at discharge and after three months will be collected. Current status: By the end of December 2018, 63 patients were included in the study. Three months of follow-up were completed, and 150 patients were expected to be included by the end of June 2019. Funding: The Department of Orthopaedics is funding this nursing research project as part of the development of nursing research.

Four of the study nurses in the nurse project. From left to right: Torunn Hammer, Eline E. Schjønneberg, Linda Andresen and Sofie Høen

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MEDICAL STUDENT PROJECTS

Student projects ACL rupture: The rates at which patients return to sports after surgical reconstruction seem to be worse than anticipated Project group: Magnus Aanstad, Medical Student Truls M. Straume-Næsheim, Postdoc Asbjørn Årøen, Professor Introduction: Rupture of the ACL is a serious knee injury. Both mass media and publicly available encyclopedias give the impression that surgery usually fixes the problem and allows the patient to return to their sport or activity at the same level as before injury. However, this might not be a realistic portrayal of the severity of the injury. Aim: The main aim of this study is to determine the rates at which patients who undergo surgical ACL reconstruction return to their sport and determine whether the portrayal of the severity of this injury by mass media and encyclopedias are realistic. Materials and methods: This meta-analysis is based on the literature found in the MEDLINE and Cochrane Library regarding ACL reconstruction and the outcome of whether the patients return to sports. Relevant studies were selected based on defined selection criteria and a systematic study quality assessment, with an objective scoring system and a defined score cut-off for inclusion. Results: Our results show that 72.2% of ACL-deficient patients return to some form of sports after surgical reconstruction but that only 56.5% return to the same level as before the injury. Current status: Data collection and analysis have been completed. An article is being written for submission to an international peer-review open access journal. Publications: The results will be published in an international peer-reviewed open access journal. Funding: We are in the process of applying for funding for open access publication. Osteochondritis dissecans of the knee

Archana Ananthaharan medical student Main supervisor: Per-Henrik Randsborg, postdoctoral fellow (Norwegian Cartilage Project)

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Introduction: Osteochondritis dissecans (OCD) is a relatively rare but well-known condition affecting the knee, elbow and ankle in children and adolescents. The reason is unknown. The prevalence of the population is not well mapped. We wanted to survey the epidemiology of and treatment results for OCD in our area. Materials and Methods: Patients aged 10-18 years who were diagnosed with OCD in the knee, elbow or ankle between 2010 and 2016 were identified via DIPS. Records were reviewed, and the MR images were classified according to the International

Cartilage Repair Society's (ICRS) classification of OCD. The patients with OCD in the knee joint were invited to answer an online questionnaire that included the KOOS (Knee injury and Osteoarthritis Outcome Score), Lysholm Score and visual analog scale (VAS) for pain. Results: In total, 134 OCDs in 113 patients were included, for whom 87 cases were in the knee joint, 24 cases were in the ankle, and 23 cases were in the elbow. The incidence was 17.2/100,000 (SD 3.5).Fifty-two (74.3%) patients with OCD in the knee joint answered the survey after an average of 48 months (5-117). Most of the patients with OCD grade I or II were treated conservatively, while patients with OCD grade III and IV were mostly operated on (p<0.001). Conservative treatment was successful in 78% of OCD grade I and II cases in the knee joint. There was five times the risk that conservative treatment would fail after OCD grades III and IV in the knee joint than after the occurrence of grades I and II. (Odds ratio = 5.2, 95% K.I. 1.3-21.2, p = 0.02). There was no statistically significant difference in KOOS, Lysholm or VAS between patients with OCD grades I-II and III-IV or between patients treated conservatively or operatively. Discussion: The incidence of OCD is currently stable compared to the figures from the 1970s. OCD in the knee joint is detected earlier (grade I and II) than OCD cases in the elbow and ankle, which are more often unstable (grade III and IV) at diagnosis. We found no difference in patient-reported results after operative and conservative treatment or between OCD grades I-II and grades III-IV, but of course, there is a clear treatment bias, since only patients with unstable OCDs or failed conservative treatment were surgically treated. Significance / Relevance: Operational treatment of unstable grade III and IV OCD in the knee is recommended to prevent patients from undergoing prolonged and failed conservative treatment. Conservative treatment, on the other hand, is successful in 8 out of 10 grade I and II OCD patients. Bruskskader I kne – sykdomsprosess og behandling Katherine Wang, Medical Student Research Program (University of Oslo), Rune B Jakobsen MD PhD, Cathrine N Engen MD PhD student and Asbjørn Årøen Professor.

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Introduction: Cartilage has a very limited ability to repair itself, and a cartilage lesion can become progressively degenerative. It is therefore important to identify lesions early in order to treat the symptoms and hopefully prevent or delay degeneration. Current forms of treatment in Norway range from conservative procedures (physiotherapy) to simpler procedures (debridement and microfracture) to more complicated procedures (transplantation of cartilage). Studies comparing the treatment forms so far have had varying results, and different subpopulations appear to respond differently to various forms of treatment. Aims: Main project: To determine any differences in gene expression in the cartilage of three different groups of patients with knee injury or osteoarthritis. Side project 1: To compare patient-reported outcomes at 10-14 years follow-up after ACL injury and cartilage damage with earlier follow-up results from 2-5 years (Røtterud et al. 2012) and 5-9 years (Ulstein et al. 2014) after surgery. Side project 2: To determine whether newly published results (Røtterud et al. 2016) affect surgeon’s choice of treatment for ACL rupture with cartilage damage in Scandinavia. Materials and methods: Main project: A total of 48 cartilage biopsies will be collected, 16 each from three different groups of patients: (1) patients with osteoarthritis, (2) patients with ACL injury and a focal cartilage lesion, and (3) patients with ACL injury without cartilage damage. The biopsies are immediately frozen, and then RNA is isolated and sequenced. Side project 1: A prospective cohort study with a matched control group using data from the Norwegian Cruciate Ligament Register (NKLR). Thirty patients registered in NKLR from 2004-2007 are included in the study with two matched controls with isolated ACL injury, per patient. Side project 2: Data from operation forms from the national cruciate ligament registers in Norway, Sweden, and Denmark will be used to compare the choice of treatment at the baseline from 2016. Standard methods of trend estimation with regression analysis and statistical process control will be used to analyze the data. Current status: Main project: Results are being analyzed. An abstract is in preparation for ICRS World Congress Vancouver 2019. A manuscript is in preparation for submission in 2019 Q3. Side projects: Approval for extension by REC achieved for side project 1, pending final approval by Data Protection Officer. X-rays and data acquisition were planned for 2019 Q2 and Q3 Funding: The project has funding from the Medical Student Research Program at the University of Oslo and South-Eastern Norway Regional Health Authority, from the Gythfeldt and Frues research fund and from the Odd-Fellow Foundation. Distale bicepssenerupturer behandlet ved Akershus universitetssykehus 2012-2016 – resultat og komplikasjoner. Project group: Helene Bakken Rontén, Medical Student, Erik Jahnsen, MD, Rune Jakobsen MD PhD

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Introduction: Ruptures of the distal biceps tendon are comparatively rare, with an incidence of 1.2-5.4 per 100,000 reported in the literature. The typical patient is male and between 40 and 60 years of age. Several surgical options for treatment exist, but none have been proven to provide superior outcomes. At Akershus University Hospital, the two-incision technique with suture anchors has been the preferred technique. Approximately 50 patients per year are treated surgically with a higher incidence than previously reported. Normally, the follow-up period does not exceed beyond 8 weeks postoperatively. Hence, we have limited knowledge about complications and long-term outcomes. Aim: We aim to assess the incidence of all distal biceps tendon ruptures treated surgically and nonsurgically during a 5-year period. The project will provide descriptive statistics for types of treatment, demographic data, recorded complications and physician and patient-reported outcomes. The results will form the basis for possible changes to the present standard of treatment at our institution. Materials and methods: This study is a retrospective quality control study using an electronic patient record. Patients treated between 2012 and 2017 will be identified using ICD and NSCP codes (S46.2 and NCL-19, -49 and -99, NBL-19, -49 and -99.) Patients will be contacted and asked to return a patient-reported outcome measure questionnaire (QuickDASH). Results: No results are available. Current status: All patients have been identified and manually confirmed. Data acquisition from the electronic patient record has been completed. Planning of questionnaire surveys for distribution among treated patients is in progress. Publications: The results will be presented at the Norwegian Orthopaedic Autumn Meeting and will be published in an open access orthopedic journal. Funding: The project has not received any specific funding. Liste over akademiske presentasjoner: None so far.

PUBLICATIONS

Publications (peer reviewed)

Alhaug OK, Berdal G, Huseby EE, Hvaal K. Flexor hallucis longus tendon transfer for chronic Achilles tendon rupture. A retrospective study. European Foot and Ankle Society. 2018 July 9, https://doi.org/10.1016/j.fas.2018.07.002 Ananthaharan A, Randsborg PH, Epidemiology and patient-reported outcome after juvenile osteochondritis in the knee. The Knee, Volume 25, Issue 4, August 2018, Pages 595-601. Ananthaharan A, Kravdal G, Straume-Næsheim TM.

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Utility and effectiveness of the Scandinavian guidelines to exclude computerized tomography scanning in mild traumatic brain injury - a prospective cohort study. BMC Emergency Medicine (2018), doi.org/10.1186/s12873-018-0193-2 Cetinkaya A, Claude PJ. Simultaneous occurrence of spinal epidural abscess and disk herniation causing irreversible neurologic deficits: A case report and review of the literature. Radiology Case Reports 13, (2018), 719–723 Clementsen S, Hammer OL, Engebretsen E, Jakobsen R, Randsborg PH. Compensation after Distal Radial Fractures. A Review of 800 claims to the Norwegian System of Patient Injury Compensation 2000-2013. The Open Orthopaedics Journal. DOI: 10.2174/1874325001812010419, 2018, 12, 419-426. Dolatowski FC, Temmesfeld M, Jerome CP, Borthne A and Hoelsbrekken SE. Bilateral symmetrical comparison of the proximal femur using 3D-CT models. Surgical and Radiologic Anatomy. 3 January 2018. Eriksen HM, Løwer HL, Tappert C, Fosse U, Myrbakk T, Berg TC, Sorknes NK, Skråmm I. Infeksjon i operasjonsområdet. Tidsskr Nor Legeforen 2018 september 17, DOI: 10.4045/tidsskr.17.0920. Fuglesang HFS, Flugsrud GB, Randsborg P-H, Hammer OL, Utvåg SE. Five-Year Follow-up Results of a Randomized Controlled Study Comparing Intramedullary Nailing with Plate Fixation of Completely Displaced Midshaft Fractures of the Clavicle in Adults. JBJS Open Access d 2018:e0009. http://dx.doi.org/10.2106/JBJS.OA.18.00009. Fuglesang F.S F, Oksum M, Wikerøy A.K.B. Mini-invasive intramedullary fixation of displaced midshaft clavicle fractures with an elastic titanium nail. Bone Joint J. 2017 Aug;99-B(8):1095-101. Garratt A, Naumann MG, Sigurdsen U, Utvåg SE, Stavem K. Evaluation of three patient reported outcome measures following operative fixation of closed ankle fractures. BMC Musculoskeletal Disorders (2018) 19:134, https://doi.org/10.1186/s12891-018-2051-5 Jakobsen RB, Gran SF, Grimsmo B, Artnzen K, Fosse E, Frich JC, Hjortdahl P. Examining participant perceptions of an interprofessional simulation-based trauma team training for medical and nursing students. Journal of Interprofessional care 2018, Vol. 32, No, 1, 80-88, https://doi.org/10.1080/13561820.2017.1376625 Oppebøen S, Wikerøy AKB, Fuglesang HFS, Dolatowski FC, Randsborg PH.

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Calcar screws and adequate reduction reduced the risk of fixation failure in proximal humeral fractures treated with a locking plate: 190 patients followed for a mean of 3 years. J Orthop Surg Res. 2018 Aug 9; 13(1):197. Oksum M, Randsborg PH. Treatment of Instability of the Proximal Tibiofibular Joint by Dynamic Internal Fixation With a Suture Button. Arthroscopy Techniques, Vol 7, No 10 (October), 2018: pp e1057-e1061, https://doi.org/10.1016/j.eats.2018.08.004 Owesen C, Røtterud JH, Engebretsen L, Årøen A. Effect of Activity at Time of Injury and Concomitant Ligament Injuries on Patient-Reported Outcome After Posterior Cruciate Ligament Reconstruction. The Orthopaedic Journal of Sports Medicine, 6(12), DOI: 10.1177/2325967118817297 Solvang HW, Nordheggen RA, Clementsen S, Hammer OL, Randsborg PH. Epidemiology of distal radius fracture in Akershus, Norway, in 2010-2011. J Orthop Surg Res. 2018 Aug 13;13(1):199 Ulstein S, Årøen A, Engebretsen L, Forssblad M, Lygre SHL, Røtterud JH. A Controlled Comparison of Microfracture, Debridement, and No Treatment of Concomitant Full-Thickness Cartilage Lesions in Anterior Cruciate Ligament-Reconstructed Knees: A Nationwide Prospective Cohort Study From Norway and Sweden of 368 Patients With 5-Year Follow-up. Orthop J Sports Med. 2018 Aug 1;6(8):2325967118787767 Ulstein S, Årøen A, Engebretsen L, Forssblad M, Lygre SHL, Røtterud JH. Effect of Concomitant Cartilage Lesions on Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction: A Nationwide Cohort Study From Norway and Sweden of 8470 Patients With 5-Year Follow-up. Orthop J Sports Med. 2018 Jul 24;6(7):2325967118786219 Årøen A. OCD: an unsolved puzzle in articular cartilage problems, Osteoarthritis and Cartilage (2018), https://doi.org/10.1016/j.joca.2018.09.008. Årøen A, Devitt BM. Penny-wise and pound-foolish. Knee Surgery, Sports Traumatology, Arthroscopy 2018, https://doi.org/10.1007/s00167-018-4852-3

Abstracts

The Norwegian Orthopaedic Society’s Autumn Meeting, Oslo, Oct 2018. Bartels S, Gjertsen JE, Frihagen F, Rogmark C, Utvåg SE. Høy morbiditet hos pasienter mellom 55 og 70 år med dislokert lårhalsbrudd (FNF). En case-control studie.

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Røtterud JH, Lygre SHL, Forssblad M, Årøen A, Engebretsen L, Ulstein S. Meniskskade og rekonstruksjon av fremre korsbånd – 5 års pasientrapportert resultat fra 8408 pasienter. Abstract 102. Wang K, Esbensen QY, Sundaram A, Jakobsen RB. Differences in gene expression between patients with traumatic cartilage injury, osteoarthritis, and healthy cartilage. Aae TF, Lian Ø, Årøen A, Engebretsen L, Randsborg PH. Pasienterstatning etter bruskkirurgi i kneleddet i Skandinavia fra 2010 til 2015. Ekås G, Moksnes H, Risberg MA, Engebretsen L. Langtidsoppfølging av barn med korsbåndskade fra 13 års alder. Oksum M, Randsborg PH. Fiksering av proksimale tibiofibulærledd med dynamisk suturbutton (demonstrasjon av en kirurgisk metode). Garratt A, Naumann MG, Sigurdsen U, Utvåg SE, Stavem K. Evaluering av 3 pasient relaterte funksjonsskårer (PROMS) etter operative fiksasjon (ORIF) av lukkede ankelfrakturer. Utvåg SE, Skjaker SA, Hoel H, Naumann MG, Sigurdsen U, Ghaneema W, Stavem K. Risikofaktorer for venøs trombo-emboli (VTE etter åpen reposisjon og osteosyntese (ORIF) av lukket ankelfraktur. Randsborg PH, Khaka R, Davies A. Konvertering fra kneartodese til kneprotese – et pasientkasus. Bartels S. Gjertsen JE, Frihagen F, Rogmark C, Utvåg SE. Høy morbiditet hos pasienter mellom 55 og 70 år med dislosert lårhalsbrudd (FNF). En case-control studie. Pollmann C, Røtterud JH, Gjertsen J-E, Dahl F, Lenvik O, Årøen A. Uforandret mortalitet etter innføring av «Fast track» for hoftebruddpasienter – en observasjonsstudie av 2230 pasienter. Cetinkaya A, Grundnes O. Akutt spinal kompartmentsyndrom hos en 27 år gammel mann. A case report. Cetinkaya A, Pierre-Jerome Claude. Simultaneous occurrence of spinal epidural abscess and disc herniation causing irreversible neurological deficit: A case report. Weldingh E, Dolatowski F, Robak OR, Hellum C, Aksnes E. VBS ved Ullevål 2015-2018.

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PRESENTATIONS Invited lectures Oslo Sports Trauma Research Center (OSTRC), Spring Seminar at Kleivstua, May 2018. Ulstein S. ACL-reconstruction and concomitant cartilage lesions Kjennvold S. Classification and management of focal cartilage injuries Sailer M. Predictors for infection after surgical reconstruction of the anterior cruciate ligament Wang K. Cartilage damage in the knees – from biology to treatment American Orthopaedic Society for Sports Medicine (AOSSM) Annual Meeting, July 2018 Ulstein S. "Effect of Concomitant Cartilage Lesions on Patient-Reported outcome after ACL Reconstruction -A National Cohort Study From Norway and Sweden of 8470 Patients With 5-Year Follow-Up" The Norwegian Orthopaedic Society’s Autumn Meeting, Oslo, October 2018.

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Dolatowski F. «Udislokerte» lårhalsbrudd – når svikter de? Faggruppe for osteoporose og benhelse symposium. Ekås G. Discoid meniscus – epidemiology, diagnosis and treatment. OSTRC symposium – Oslo Sports Trauma Research Center. Wang K. Differences in Gene Expression Between Patients with Traumatic Cartilage Injury, Osteoarthritis, and Healthy cartilage. Frie foredrag. Randsborg PH. Konvertering fra kneartrodese til kneprotese – et pasientkasus. Frie foredrag. Ekås G. Knepatologi hos unge voksne etter fremre korsbåndsskade før 13 års alder. Frie foredrag. Ekås G. Langtidsoppfølging av barn med korsbåndskade før 13 års alder. Frie foredrag. Utvåg SE. Evaluering av 3 pasient relaterte funksjonsskårer (PROMs) etter operative fiksasjoner (ORIF) av lukkede ankelfrakturer. Frie foredrag. Utvåg SE. Risikofaktorer for venøs trombo-emboli (VTE) etter åpen reposisjon og osteosyntese (ORIF) av lukket ankelfraktur. Frie foredrag. Utvåg SE. Høy morbiditet hos pasienter mellom 55 og 70 år med dislosert lårhalsbrudd (FNF). En case-control studie. Frie foredrag. Cetinkaya A. Simultaneous occurrence of spinal epidural abscess and disc herniation causing irreversible neurological deficit: A case report. Frie foredrag. Cetinkaya A. Akutt spinal kompartmentsyndrom hos en 27 år gammel mann. A case report. Frie foredrag. Bønes I. Kan skruepenetrasjon etter plateosteosyntese av proksimale humerusfrakturer reduseres? Frie foredrag. Seminar at Oppdal 2018 Fuglesang H. Advanced fracture course. Other lectures ESSKA Congress, Glasgow, May 2018 Straume-Næsheim T.M. “Active rehabilitation versus Mpfl reconstruction in patients with chronic lateral patella dislocations. A randomized controlled trial”. Straume-Næsheim T.M. “Concussion: Are they preventable?”

Arranged seminars/meetings

Orthopaedic Research Group seminar, Akershus University Hospital, June 2018.

Pollmann C. Fordypningsstillings - prosjektet

Hammer OL. Hva har vi lært av radiusforskningen og hvordan kan resultatene implementeres?

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Fuglesang H. Hva har vi lært av forskning på clavikulafrakturer og hvordan kan resultatene implementeres?

Orthopaedic Symposium, “Skader i øvre ekstremiteter - behandling, utfordringer og prognose". Akershus University Hospital October 2018,

Fuglesang H. Claviculafrakturer Hammer OL. Volar låseplateplate versus ekstern fiksasjon på intra-artikulære distale radiusfracturer Hesla E. Olecranonfrakturer Jakobsen J.R. Skader i overekstremiteten hos barn Stømner HC. Konservativ behandling og opptrening etter proximale humurusfrakturer Wikerøy A. Plate versus nagling av proximale humurusfrakturer Friday meeting, open for all employees at Akershus Universitetssykehus. Wang K. Forskerlinjen – en viktig ressurs for et universitetssykehus Wikerøy A. Humerusfrakturer – plate eller skruer? Randsborg P.H. Hva kan vi lære av andres feil i ortopedisk kirurgi? Internal lessons at the morning meeting, Akershus Universitetssykehus Mjønes S. Rygg: Sagital Balanse Poster Presentations ESSKA Congress, Glasgow, May 2018 Randsborg PH. “Epidemiology and patient-reported outcome after juvenile osteochondritis dissecans in the knee” Randsborg PH. “Compensation after treatment for anterior cruciate ligament injuries” Academic assignments

Supervising activity Main supervisor for Katherine Wang, Medical Student Research Program, University of Oslo, Jakobsen R. Main supervisor for Thomas A Øverby, Medical Student, University of Oslo, Jakobsen R. Main supervisor for Ingi Thor Hauksson, Akershus University Hospital, Randsborg PH. Main supervisor for Ståle Clementsen, Akershus University Hospital, Randsborg PH. Main supervisor for Stian Kjennvold, Akershus University Hospital, Randsborg PH. Main supervisor for Annette Wikerøy, Akershus University Hospital, Randsborg PH. Main supervisor for Stud. Med. Archana Ananthaharan, University of Oslo, Randsborg PH. Main supervisor for Svend Ulstein, Akershus University Hospital, Røtterud JH. Main supervisor for Christian Pollmann, Akershus University Hospital, Årøen A. Main supervisor for Magnus Aanstad, Medical Student, University of Oslo, Årøen A.

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Cosupervisor for Ståle Clementsen, Akershus University Hospital, Jakobsen RB. Cosupervisor for Ola-Lars Hammer, Akershus University Hospital, Randsborg PH. Cosupervisor for Tommy Frøseth Aae, Kristiansund Hospital, Randsborg PH. Cosupervisor for Ingi Thor Hauksson, Akershus University Hospital, Årøen A. Cosupervisor for Ståle Clementsen, Akershus University Hospital, Årøen A. Cosupervisor for Buru Gilbert Moatsh, Akershus University Hospital, Årøen A.

Reviewer Reviewer for JBJS – Journal of Bone and Joint Surgery, Årøen A. Reviewer for AJSM – American Journal of Sports Medicine, Årøen A. Reviewer for BMC Musculoskeletal Dirsorders, Årøen A. Reviewer for Cartilage, Årøen A. Reviewer for Acta Ortopedica, Randsborg PH. Reviewer for JBJS – Journal of Bone and Joint Surgery, Randsborg PH. Reviewer for KSSTA – Knee Surgery, Sports Traumatology Arthroscopy, Randsborg PH. Reviewer for BMJ – British Medical Journal, Ulstein S. Reviewer for AJSM – American Journal of Sports Medicine, Røtterud JH. Reviewer for KSSTA – Knee Surgery, Sports Traumatology Arthroscopy, Røtterud JH. Reviewer for KSSTA – Knee Surgery, Sports Traumatology Arthroscopy, Straume-Næsheim T. Editor Associate Editor for BMC Musculoskeletal Disorders, Årøen A. Associate Editor for JBJS Open Access (JBJS OA), Randsborg PH. Faglig medarbeider Tidsskriftet, Randsborg PH. Editorial Board Member OJSM – Ortopedic Journal of Sports Medicine, Røtterud JH.

MEDIA Hendrik Fuglesangs article “Plate fixation versus intramedullary nailing of completely displaced midshaft fractures of the clavicle. A prospective randomized controlled trial.” Bone Joint J. 2017 Aug; 99-B (8):1095-1101., was chosen for presentation in Evidence-Based Orthopaedics in J Bone Joint Surge Am. Annette Wikerøy`s project “Plate fixation versus intramedullary nailing of 3 and 4 part proximal humerus fractures” was presented in an article in Forskning.no, as part of the research at Ahus: https://forskning.no/akershus-universitetssykehus-hf-medisinske-metoder/skal-finne-den-beste-behandlingen-av-kompliserte-skulderbrudd/1120855

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RESEARCH FUNDING 2018

Distribution of research funding in the Orthopaedic Research Group 2018

8 %

77 %

12 %

1 % 1 % 1 %

South-Eastern Norway Regional Health Authority Cross-regional funds

Sophies Minde Ortopedi AS Other

Ortomedic AS Charnley Scholarship The Norwegian Orthopaedic Society

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Project Source

Articular Cartilage Defect in the ACL Injured Knee. Årøen A. South-Eastern Norway Regional He

Treatment result after acute Achilles tendon rupture. Hoelsbrekken SE. South-Eastern Norway Regional He

The Norwegian Cartilage Project: A Multidisciplinary Approach to Improve the Treatment of Injured Articular Cartilage. Årøen A.

Cross-regional funds

Reconstruction of the medial patellofemoral ligament versus conservative treatment of recurrent patella dislocation. A Randomised Controlled Trial. Straume-Næsheim TM.

South-Eastern Norway Regional He

MPFL project. Straume-Næsheim TM. Sophies Minde Ortopedi AS 2011-2

Undisplaced fractures of the femoral neck in the elderly. Dolatowski FC. Sophies Minde Ortopedi AS 2013

Intramedullary nailing versus fixation of displaced midshaft clavicle fracture. Fuglesang HSF. Sophies Minde Ortopedi AS 2013

Microfracture versus mosaicplasty. Ulstein S. Sophies Minde Ortopedi AS 2013

"The Senior Study" - Radius fractures in the elderly. Hammer OL. Sophies Minde Ortopedi AS 2014

Treatment and functional outcome in patients with displaced femoral neck fractures younger than 70 years. Bartels S.

Sophies Minde Ortopedi AS 2014-2

Fast-Track. Pollmann C. Sophies Minde Ortopedi AS 2014

Dupuytren’s disease study. Hauksson I. Sophies Minde Ortopedi AS 2014

Plate fixation versus intramedullary nailing of 3 and 4 part proximal humerus fractures. A prospective, double blinded randomized controlled trial. Wikerøy A.

Sophies Minde Ortopedi AS 2017

Norwegian Spinal stenosis study. Grundnes O. Møre og Romsdal Health Authority

Supplerende anatomistudie til "3-D CT på innkilte lårhalsbrudd". Temmesfeld M. Ortomedic AS Charnley Scholarshi

Debridement, antibiotics and implant retention (DAIR) for infected total hip arthroplasty- does the operative approach influence the functional result Pollmann C. Ortomedic AS Charnley Scholarshi

Monitoring orthopedic infections following cruciate ligament surgery and joint arthroplasty. Sailer M.

The Norwegian Orthopaedic Socie

Fast-Track hoftebrudd. Pollmann C. Heraus Medical

Bruskskader I kne – sykdomsprosess og behandling. Jackobsen RB Odd fellows

Total

Overview of existing funding for each pro