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The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS) is, to date, the most widely used scale for evaluating foot and ankle disorders. We translated it into Danish and evaluated the reliability, validity and responsiveness of the Danish version of the AOFAS-AHS (AOFAS-DK) in patients aged >18 years with isolated ankle-related fractures. Forward-backward translation, cross-cultural adaption, and validation study were performed. In total, 125 patients completed the AOFAS-DK and the Self-reported Foot and Ankle Score (SEFAS) at 3 time points after the date of fracture. The evaluation was performed according to the Consensus-based Standards for the selection of health Measurement Instruments guidelines. The intra-class correlation coefficient level of the AOFAS-DK total score was 0.87 (95% confidence interval: 0.80-0.91). Cronbach's alpha (CA) for the AOFAS-DK function subscale was 0.62, whereas the floor and ceiling effect of the function subscale was 32% (T1) and 19% (T2), respectively. Construct validity was correlated with the SEFAS, and >75% of the predefined hypotheses could be confirmed. Responsiveness was analyzed using longitudinal data, and showed that the AOFAS-DK can detect changes in scores. The Danish version of the self-administered section of the AOFAS-AHS showed overall good reliability, validity, and responsiveness. The low CA values and the presence of the floor effect might be due to the low number of items and response options available in the scale. The AOFAS-DK can be used to evaluate physical function in patients with ankle-related fractures.

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INTRODUCTION: Fracture of the distal radius (DRF) is one of the most common fractures treated by orthopaedic surgeons. The most common operative treatments of these fractures are open reduction and internal fixation. The incidents and types of complications associated with the use of these operations have not been studied in detail. MATERIAL AND METHODS: We performed a retrospective study documenting types of complications and their occurrence in a group of patients who received open reduction and internal fixation. Our definition of a complication was a case in which the patient had one or more complications which required an operation, or suffered from complex regional pain syndrome, or skin healing problems lasting more than four weeks from the operation. RESULTS: A total of 165 patients were included. In all, 39 complications in 30 wrists were registered: i.e. 18% had a minimum of one complication. CONCLUSION: Our finding that 18% suffer from a serious complication when treated using a volar locking plate must be taken into consideration when surgeons choose between conservative or operative treatment for DRF treatment. A few other studies have looked at the incidents of complications and have reported similar results. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

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INTRODUCTION: The impact of Scheuermannss disease (SD) on health-related quality of life (HRQoL) is unclear. The aim of this study was to study HRQoL based on The Medical Outcome Study Short Form-12 (SF-12) in adult life in a group of SD patients. MATERIAL AND METHODS: A total of 46,418 twins were sent a questionnaire. 75.3% answered. Included in the questionnaire were questions from the SF-12. We compared SF-12 values in SD patients and control patients. We also identified 259 "non-concordant" twin pairs and compared SF-12 values from the SD twin with values from the healthy twin. RESULTS: In all, 943 persons were identified to have SD, leaving 33,064 persons in the control group. SF-12 Physical Component Summary (PCS) (mean (standard deviation)) was found to be 50.50 (9.89) in SD and 53.21 (8.00) in controls (p < 0.001), and SF-12 Mental Component Summary (MCS) was found to be 51.52 (8.49) in SD and 51.81 (8.45) in controls (p = 0.71). In the non-concordant twin pairs, SF-12 PCS was found to be 50.74 (9.87) in SD and 52.74 (8.84) in controls (p < 0.001), and SF-12 MCS was found to be 53.91 (8.19) in SD and 53.72 (8.70) in controls (p = 0.64). CONCLUSION: SF-12 PCS is moderately, though highly statistically significantly worse in SD patients than in controls in this big group of twins. We found no statistical difference in SF-12 MCS between the two groups. SD patients evaluate their physical health worse and their mental health like controls. FUNDING: This study was funded by The Sahva Foundation. The sponsor had no influence on the study or its publication. No conflicts of interest exist between the sponsor and the authors. TRIAL REGISTRATION: Approved by the Scientific-ethical Committee in Denmark (no. 20010202).

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In vitro studies have shown that selective serotonin reuptake inhibitors inhibit platelet aggregation. It is well documented that SSRIs cause serious gastrointestinal bleeding, but studies on other bleeding manifestations have been equivocal. Our objective was to determine a possible association between use of serotonergic antidepressants (SA) and perioperative bleeding during hip replacements. We conducted a retrospective study between 1 January 2007 and 30 June 2012 among patients that underwent a primary unilateral uncemented total hip arthroplasty (THA). Information was collected on the observed blood loss and the need for blood transfusions among this group. We compared the blood loss between users of SA, users of non-serotonergic antidepressants (NSA) and non-users, while adjusting for potential confounders using multivariate linear regression. We indentified 1318 patients that underwent a THA in the study period. The average volume of surgical bleeding was 350 ml. The adjusted incremental blood loss associated with use of SA and NSA was 93, 95% confidence interval (38-147) ml and -50 (-125 to 25) ml compared with non-use. Only 48 subjects (3.6%) had transfusions. Use of SA was associated with an increased blood loss compared with non-users. The hypothesis that SA impairs haemostasis is supported by these results.

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INTRODUCTION: The aetiology of congenital clubfoot is unclear. Although studies on populations, families, and twins suggest a genetic component to the aetiology, other studies have identified environmental factors. The purpose of this study was to calculate heritability in order to determine to what extent genetic and/or environmental factors contribute to the aetiology of congenital clubfoot and to asses whether there was a change in the prevalence over time. MATERIALS AND METHODS: The Odense based Danish Twin Registry is unique as it contains data on all the approximately 85,000 twin pairs born in Denmark over the last 140 years. All 46,418 twin individuals born from 1931 through 1982, who had earlier consented to contact, received a 17-page Omnibus questionnaire in the spring of 2002. Data were analysed with structural equation models to identify the best fitting aetiological model based on a balance of goodness-of-fit and parsimony and to estimate heritability. RESULTS: We found an overall self-reported prevalence of congenital clubfoot of 0.0027 (95 % confidence interval 0.0022-0.0034). Fifty-five complete (both twins answered the question) twin pairs were identified representing 12 monozygotic, 22 same-sex dizygotic, 18 opposite-sex dizygotic, and 3 with unclassified zygosity. The model with only environmental factors (CE) was best fitting based on AIC, and the model with an additive genetic factor (ACE) came in second. Due to the small statistical power, we hypothesise that the model with both genetic and environmental effects (ACE) was the better model. Choosing the ACE-model we found a heritability of clubfoot of 30 %. Regression coefficient for age was -0.002 (-0.011 to 0.005), indicating that there has been no change in prevalence of clubfoot over the 50-year age span we examined. DISCUSSION: We conclude that non-genetic factors must play a role, and a genetic factor might contribute, in the aetiology of congenital clubfoot.

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BACKGROUND AND PURPOSE: The genetic/environmental etiology of Scheuermann's disease is unclear. We estimated the heritability of the disease using an etiological model adjusted for sex and time of diagnosis, and examined whether the prevalence of Scheuermann's disease was constant over time. METHODS: 46,418 twins were sent a questionnaire about health and disease. Of these, 75% returned the questionnaire and 97% answered the question "Have you been diagnosed as having Scheuermann's disease by a doctor?" RESULTS: Responders included 11,436 complete pairs of twins. Data were analysed using classical twin modeling methods. Tetrachoric correlations were used to decide which etiological model to fit. The best-fitting model was the AE model. Heritability was 0.74 (95% CI: 0.65-0.81), while variance explained by environmental factors was 0.26 (95% CI: 0.19-0.35). A threshold of 2.1 (95% CI: 1.9-2.2) was calculated, corresponding to a prevalence of 1.9% (95% CI: 1.3-2.8) for women. Regression coefficients for age and sex were 0.000 (95% CI: -0.003 to 0.002) and -0.32 (95% CI: -0.42 to -0.23). INTERPRETATION: We found a heritability of 0.74 in Scheuermann's disease. The threshold in men was lower than in women, corresponding to a male prevalence that was almost twice that of females. We found no change in the prevalence of Scheuermann's disease throughout the 50-year age span that we examined.

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INTRODUCTION: The Ottawa ankle rules (OAR) is a tool physicians may use to determine whether or not to perform an x-ray after an ankle or midfoot distortion or blunt trauma to these structures. The rationale of using the OAR is to exclude a fracture by means of clinical examination without resort to x-rays, and thereby limiting the use of x-rays, time, costs, etc. The principle of the OAR is that an ankle x-ray is only required when there is bone tenderness along the distal six centimetres of the posterior part of the medial or lateral malleolus, or when the patient is unable to bear weight immediately after the accident and in the emergency department (ED). Similarly, an x-ray of the midfoot is required only when there is bone tenderness at the base of the 5th metatarsal or the navicular bone, or when the patient is unable to bear weight immediately after the accident and also in the ED. Our hypothesis was that by introducing the OAR, we would reduce the use of x-rays without increasing the number of missed fractures. MATERIAL AND METHODS: The study was designed as an intervention study with 882 patients in the control group and 1,014 patients in the intervention group. The intervention consisted of several OAR implementation measures. RESULTS: Before use of the OAR, 62% had an x-ray taken. This proportion was reduced to 57% with the introduction of the OAR. We registered a significant reduction (p < 0.001) in x-ray without increasing the number of missed fractures. CONCLUSION: The OAR may reduce the number of x-rays and possibly also save costs and time if implemented in Denmark.

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We hereby report a case of self mutilation against the right upper extremity in a 26-year-old male. The condition started after a minor trauma. After a few days the diagnosis compartment syndrome was suspected and a fasciectomy of the forearm was performed. The patient subsequently claimed that he had experienced further symptoms. Despite countless investigations, it was not possible to identify the course of the patient's symptoms. It has become clear that the patient suffers from >>Münchhausen's syndrome<<.

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INTRODUCTION: Surgical treatment of lateral epicondylitits (LE) has not been investigated sufficiently to allow general guidelines, nor has non-invasive treatment produced sufficiently good results. We present the results of 31 mini-tenotomies performed to treat lateral epicondylitis. MATERIALS AND METHODS: We performed a retrospective follow-up study of 31 elbows treated with mini-tenotomy for LE. The average period with symptoms was 125 weeks, the average follow-up 73 weeks. The mini-tenotomies were performed under local anaesthesia and the extensor aponeurosis was cut close to the epicondyl. RESULTS: A total of 27 of 31 patients reported that their LE had become much better or that all the pain had gone. The Quick DASH score decreased from 66 preoperatively to 13 at the follow-up (p < 0.001). Surgery achieved its maximal effect on average four weeks after surgery. Two patients experienced that the pain came back. CONCLUSION: A prospective randomised investigation is warranted; yet, the present results indicate that mini-tenotomy could be a promising treatment for a selected group with isolated LE.

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BACKGROUND AND PURPOSE: THA changes the pattern of strain distribution in the proximal femur. We quantified the changes in BMD for 5 years after insertion of the cemented Exeter stem in women. METHODS: 18 women aged 55-79 years, undergoing unilateral THA with the cemented Exeter stem, were included in the study. The BMD was measured in 7 femoral regions of interest according to Gruen, and the contralateral hip and spine using dual-energy X-ray absorptiometry postoperatively, at 18 and at 60 months of follow-up. Results were tested using Wilcoxon matched-pairs signed-rank test. RESULTS: During the first 18 months, a significant decrease in BMD was seen in zones 2, 3, 6, and 7. No significant changes were seen in zones 4 and 5, in the contralateral hip, or at the spine. In zone 1, there was a small but significant rise in BMD. From 18 to 60 months, we observed a statistically significant rise in BMD in all zones except 4 and 7. Despite this, the total periprosthetic BMD decreased during the follow-up relative to the immediate postoperative situation. There was no significant reduction in BMD in the contralateral hip. In the spine, we observed a significant rise in BMD. INTERPRETATION: 18 months after THA, BMD had decreased in Gruen zones 2, 3, 6, and 7. The bone loss was similar to that seen after other implants and appears to be related to the changes in stress pattern within the proximal femur. At 5 years, BMD had increased again in these zones. It remained lower than baseline, however.

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BACKGROUND: The purpose of this study was to establish a cohort of symptomatic twins with Scheuermann kyphosis to provide estimates of prevalence, concordance, odds ratio, and heritability. These estimates indicate to what extent genetic factors contribute to the etiology of this disease. METHODS: The Odense-based Danish Twin Registry is unique in that it contains data on all 73,000 twin pairs born in Denmark over the last 130 years. For the present study, all 46,418 twins born from 1931 through 1982 received a seventeen-page questionnaire, in which one question was "Have you been diagnosed with Scheuermann disease by a doctor"? The prevalence of self-reported Scheuermann disease was calculated, with the total number of answers used as the general population. Pairwise and probandwise concordance, odds ratio, tetrachoric correlations, and heritability were calculated. RESULTS: We found that the overall prevalence of Scheuermann disease was 2.8%, with a prevalence of 2.1% among women and 3.6% among men (p < 0.0001). The pairwise concordance for monozygotic twins was 0.19 compared with 0.07 for dizygotic twins. The probandwise concordance was 0.31 for monozygotic twins and 0.13 for dizygotic twins. The odds ratios were 32.92 and 6.25 in the monozygotic and dizygotic twins, respectively. These differences were significant (p < 0.01). Heritability was 74%. CONCLUSIONS: In a large cohort of twins that included almost 35,000 individuals, the self-reported overall prevalence of Scheuermann disease was 2.8% and the male-to-female ratio was close to 2:1. Because the pairwise and probandwise concordance and the odds ratio were two to three times higher in monozygotic than in dizygotic twins and the heritability was high, we concluded that there is a major genetic contribution to the etiology of Scheuermann disease.

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INTRODUCTION: The aim of this study was to evaluate the effect of inhibition of gastric acid secretion on postprandial pancreatic secretion. MATERIAL OG METHODS: Fifteen healthy subjects and seven patients with chronic pancreatitis were entered in a randomised, double-blind, cross-over study of the exocrine pancreatic function after placebo or omeprazole 80 mg daily for three days. The exocrine pancreatic function was evaluated with the Lundh test. The pH was determined in the duodenum, and CCK and secretin were determined in plasma. RESULTS: As expected, a higher intraduodenal pH was found after inhibition of the gastric acid secretion, but no significant difference was seen in the concentration of pancreatic amylase in the duodenum. None of the subjects changed their diagnostic category during the test. Except for those with pancreatic insufficiency, in whom plasma secretin was lower after omeprazole, inhibition of gastric acid secretion had no effect on CCK or secretin in plasma. DISCUSSION: Inhibition of gastric acid secretion with high doses of omeprazole does not alter postprandial intraduodenal concentrations of alpha-amylase. It does not, therefore affect the evaluation of the Lundh test.

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INTRODUCTION: The treatment of an ACL lesion in patients who are above 40 years of age remains controversial. The aim of this study is to report the subjective impression of the result after ACL reconstruction in 24 such patients. MATERIAL AND METHODS: The records of 24 patients, who were aged 40 or older when they had ACL reconstruction were reviewed. The average age was 43 years (40-49), 10 women and 14 men. The mean interval between injury and operation was 35 months (6-185). All 24 patients completed a self-administered questionnaire to evaluate A) preoperative status, B) the rehabilitation period, and C) postoperative status and their overall view of the treatment. Status was made 16 months postoperatively (5-41). RESULTS: Preoperatively, 23 out of 24 patients had instability problems in daily living (ADL) and at work. One had not experienced the knee giving way. All the patients had experienced pain. Postoperatively, 21 out of the 24 experienced no instability and 14 are free of pain. Eighteen have increased activity, five have no change in activity, and one has decreased activity. Sixteen are satisfied with the level of postoperative activity. Twenty-two find their knee status better postoperatively than preoperatively. One finds it unchanged, and one finds it worse. Overall 15 patients find result very satisfying, seven find it satisfying, and two find it poor. Twenty-two would advise others in a similar situation to have the operation done, whereas one is in doubt and one would not recommend the operation. DISCUSSION: We conclude that the results of ACL reconstruction in patients above the age of 40 are as good as those in younger patients.

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