Ultrasound-Assisted Endoscopic Removal of Pretibial Cysts Related to Biointerference Screw Degradation

We report on the treatment of cases of painful subcutaneous pretibial cyst due to broken and displaced materials of only partly absorbed bioabsorbable interference screws used for anterior cruciate ligament reconstruction. Ultrasound examination was used to both make the definite diagnosis and determine the exact localization of dislodged screw parts. The broken and loose bioabsorbable screw parts and surrounding cyst-like structure were removed endoscopically by a soft-tissue resector.publishedVersio

Clinical outcome after mosaicplasty of knee articular cartilage defects of patellofemoral joint versus tibiofemoral joint

Background The purpose was to investigate survival of cartilage repair in the knee joint by osteochondral autograft transfer stratified by location of the lesion; patellofemoral joint (N = 26) versus the medial or lateral femoral condyles (N = 58). Methods For survival analyses, “failure” was defined as the event of a patient reporting a poor Lysholm score (below 65 points) or undergoing a knee replacement procedure. Results The survival distribution was not significantly different between the patellofemoral joint and the tibiofemoral joint groups. Conclusions The current study suggest that similar long-term outcome can be expected after OAT procedures for the patellofemoral or tibiofemoral joint.publishedVersio

Failed meniscal repairs after anterior cruciate ligament reconstruction increases risk of revision surgery

Background: Failed anterior cruciate ligament (ACL) reconstruction (ACLR) can lead to reduced quality of life because of recurrent episodes of instability, restrictions in level of activity, and development of osteoarthritis. A profound knowledge of the causes of a failed surgery can ultimately help improve graft survival rates. Purpose: To investigate the patient-related risks of inferior outcomes leading to revision surgery after ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: From a prospective cohort of primary ACLRs performed at a single center, patients who required later revision surgery were matched with a control group of uneventful primary ACLRs. Patient characteristics, data from the preoperative examinations, KT-1000 arthrometer laxity testing, Tegner activity scale, International Knee Documentation Committee subjective score, Knee injury and Osteoarthritis Outcome Score, and perioperative data from the initial surgery were included. Results: A total of 100 revision cases and 100 matched controls, with a median follow-up time of 11 years, were included in the study. Those who had undergone revision surgery were younger at the time of reconstruction and had a shorter time from injury to surgery than their matched controls (P = .006). The control group—of uneventful ACLRs—had a higher incidence of meniscal repair at reconstruction (P = .024). Also, the revision group more frequently experienced later failure of the previous meniscal repair (P = .004). Surgeon experience was not found to affect the risk of revision ACL surgery. Those who had undergone ACL revision surgery had more frequently received a hamstring tendon graft size of <8 mm (P = .018) compared with the controls. Conclusion: The current study demonstrated that failed meniscal repair and a hamstring tendon graft size of <8 mm were associated with primary ACLR failure. Also, younger age at the time of surgery and shorter time from injury to surgery were found to affect the risk of undergoing revision ACL surgery.publishedVersio

Computed Tomography Assessment of Anatomic Graft Placement After ACL Reconstruction: A Comparative Study of Grid and Angle Measurements

Background: The anatomic placement of anterior cruciate ligament (ACL) grafts is often assessed with postoperative imaging. In clinical practice, graft angles are measured to indicate anatomic placement on magnetic resonance imaging, whereas grid measurements are performed on computed tomography (CT). Recently, a study indicated that graft angle measurements could also be assessed on CT. No consensus has yet been reached on which measurement method is best suited to assess anatomic graft placement. Purpose: To compare the ability of grid measurements and angle measurements to identify anatomic versus nonanatomic tunnel placement on CT performed in patients undergoing ACL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: A total of 100 knees undergoing primary reconstruction with a hamstring graft (HAM group), 91 undergoing reconstruction with a bone–patellar tendon–bone graft (BPTB group), and 117 undergoing revision ACL reconstruction (REV group) were assessed with CT. Grid measurements of the femoral and tibial tunnels and angle measurements of grafts were performed. Graft placement, rated as anatomic or nonanatomic, was assessed with both methods. Pearson chi-square, analysis of variance, Kruskal-Wallis, and weighted kappa tests were performed as appropriate. Results: The grid assessment classified 10% of the HAM group, 4% of the BPTB group, and 17% of the REV group as nonanatomic (P < .001). The angle assessment classified 37% of the HAM group, 54% of the BPTB group, and 47% of the REV group as nonanatomic. The weighted kappa between angle measurements and grid measurements was low in all groups (HAM: 0.009; BPTB: 0.065; REV: 0.041). Conclusion: The agreement between grid measurements and angle measurements was very low. The angle measurements seemed to overestimate nonanatomic tunnel placement. Grid measurements were better in identifying malpositioned grafts.publishedVersio

The Effect of Posterior Tibial Slope on the Risk of Revision Surgery After Anterior Cruciate Ligament Reconstruction

Background: A significant proportion of patients undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) later experience graft failure. Some studies suggest an association between a steep posterior tibial slope (PTS) and graft failure. Purpose: To examine the PTS in a large cohort of patients about to undergo ACLR and to determine whether a steep PTS is associated with later revision surgery. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective review of a cohort undergoing isolated ACLR between 2002 and 2012 (with 8-19 years of follow-up) was conducted. Preoperative sagittal radiographs of knees in full extension were used for measurements of the PTS. There were 2 independent examiners who performed repeated measurements to assess the reliability of the method. Statistical analyses were performed to compare the PTS in the groups with and without later revision surgery. Results: A total of 728 patients, with a mean age of 28 years at the time of surgery, were included. Overall, 10% (n = 76) underwent revision surgery during the observation period. The group of injured knees had a significantly steeper PTS compared with the group of uninjured knees (9.5° vs 8.7°, respectively; P < .05). The mean PTS in the no revision group was 9.5° compared with 9.3° in the revision group (not significant). Dichotomized testing of revision rates related to PTS cutoff values of ≥10°, ≥12°, ≥14°, ≥16°, and ≥18° showed no association of PTS steepness (not significant) to graft failure. Patients with revision were younger than the ones without (mean age, 24 ± 8 vs 29 ± 10 years, respectively) and had a shorter time from injury to ACLR (mean, 14 ± 27 vs 24 ± 44 months, respectively) as well as a smaller graft size (8.2 vs 8.4 mm, respectively; P = .040). Conclusion: The current study did not find any association between a steep PTS measured on lateral knee radiographs and revision ACL surgery. However, a steeper PTS was seen in the group of injured knees compared with the group of uninjured (contralateral) knees. Independent of the PTS, younger patients, those with a shorter time from injury to surgery, and those with a smaller graft size were found to undergo revision surgery more often.publishedVersio

Shoulder instability surgery in Norway: The first report from a multicenter register, with 1-year follow-up

Background and purpose. In January 2008, we established the Norwegian Register for Shoulder Instability Surgery. We report on the establishment, the baseline data, and the results at 1-year follow-up. Methods. Primary and revision shoulder stabilization is reported by the surgeon on a 1-page paper form containing the patient's history of shoulder injury, clinical findings, and perioperative findings. The WOSI questionnaire for self-assessment of shoulder function is completed at baseline and at follow-up after 1, 2, and 5 years. To evaluate the completeness of registration, we compared our data with those in the Norwegian Patient Registry (NPR). Results. The NPR reported 39 hospitals performing shoulder stabilizations. 20 of these started to report to our register during 2009, and 464 procedures (404 primary, 59 revisions) were included up to December 31, 2009, which represented 54% of the procedures reported to NPR. Of the 404 primary procedures, 83% were operations due to anterior instability, 10% were operations due to posterior instability, and 7% were operations due to multidirectional instability. Arthroscopic soft tissue techniques were used in 88% of the patients treated for primary anterior instability and open coracoid transfer was used in 10% of such patients. At 1-year follow-up of 213 patients, we found a statistically significantly improved WOSI score in all types of instability. 10% of the patients treated with arthroscopic anterior labral repair and 16% treated with arthroscopic posterior labral repair reported recurrent instability. No statistically significant difference in functional improvement or rate of recurrence was found between these groups. Interpretation. The functional results are in accordance with those in previous studies. However, the incidence of recurrent instability 1 year after arthroscopic labral repair is higher than expected.publishedVersio

Hvordan fungerer samvirke mellom landbaserte nødetater og maritime ressurser ved ulykker i umiddelbar nærhet til land? Et kvalitativt blikk på redningsarbeidet etter helikopterulykken ved Turøy.

Bacheloroppgave i beredskap og krisehåndtering 2017Vi har valgt samvirke, og konkret samvirke mellom landbaserte nødetater og maritime ressurser, som tema for vår oppgave. Utfordringer knyttet til samordning og koordinering har vært tilbakevendende i flere av fagene i studiet, noe som gjør at vi synes dette både er interessant og aktuelt å se nærmere på. Vi mener også at det kan finnes en slags gråsone i grensesnittet mellom land og sjø, og håper derfor at vår avhandling kan være med på å øke kunnskapen og komme med forslag til forbedringer på dette området. Identifisering av gråsoner og uavklarte ansvarsforhold innenfor beredskapsfeltet er også noe som har vært forankret fra høyeste hold i forvaltningen: «Riksrevisjonen mener Justisdepartementet i større grad burde ta initiativ til et systematisk arbeid for å identifisere gråsoner på tvers av departementsområder, og stiller spørsmål ved om det kan eksistere gråsoner eller uavklarte ansvarsforhold som ikke er avdekket. I Soria Moria-erklæringen sier regjeringen at den vil avklare og kartlegge beredskapsmessige gråsoner» (Det kongelige justis- og politidepartement, 2008, s. 17). I Stortingsmelding 29, 2011-2012, Samfunnssikkerhet, ble samvirke mellom aktører som har en rolle i det nasjonale samfunnssikkerhets- og beredskapsarbeidet løftet frem som en viktig forutsetning for å sikre best mulig utnyttelse av ressurser på tvers av sektorer (Det kongelige justis- og beredskapsdepartement, 2012). Dette i stor grad basert på hendelsene 22. juli 2011, hvor man i ettertid har måtte erkjenne at samvirke mellom aktørene ikke fungerte optimalt. I Gjørv-kommisjonens rapport har det blitt blant annet blitt løftet frem eksempler på at dårlig eller manglende kommunikasjon mellom aksjonerende enheter førte til at man gikk glipp av muligheter underveis (NOU 2012:14, 2012). Med bakgrunn i teorien vi har gjennomgått i studiet, samt informasjon hentet fra offentlige utredninger, rapporter og andre tilgjengelige kilder, ser vi at det finnes en del avhengigheter mellom de ulike beredskapsaktørene som bare kan håndteres gjennom godt samvirke. En god forståelse av samvirkebegrepet, samt hvilke elementer som må være på plass for å sikre et godt samvirke vil derfor være vesentlig for at dette skal fungere i praksis. Metodisk har vi valgt å gjøre kvalitative undersøkelser, i form av intervjuer med nøkkelpersoner som var involvert i håndtering av en konkret hendelse, nemlig helikopterulykken ved Turøy i 2016. Utfra omtale i media, offentlige rapporter og andre åpne kilder vurderte vi denne ulykken som representativ for hendelser hvor et godt samvirke mellom landbaserte og maritime ressurser må ha vært avgjørende for et optimalt resultat. Våre funn kan indikere at nøkkelfaktorer knyttet til kompetanse, kommunikasjon, ansvar, samvirke og evaluering er avgjørende for en effektiv håndtering av hendelser av denne typen. De involverte partene må ha en god grunnkompetanse som også inkluderer god kjennskap til aktuelle samarbeidspartnere, som igjen legger til rette for god kommunikasjon og en klar forståelse av ansvarsforhold og rapporteringsveier som er avgjørende for å få til godt samvirke. For å slutte sirkelen må man også gjennomføre gode evalueringer og sikre erfaringstilbakeføring som igjen øker den totale kompetansen og evnen til å håndtere tilsvarende hendelser.English abstract We have chosen cooperation, and more specifically cooperation between land-based emergency services and maritime resources, as the topic of our thesis. Challenges associated with coordination is something that has been mentioned in several of the subjects in our field of study, which makes it both interesting and relevant to look into. We also believe that there may be some kind of gray area in the interface between land and sea, and therefore hope that our dissertation can help raise knowledge and make suggestions for improvements in this area. Identification of gray areas and unclear responsibilities within the emergency response field is also something that has been rooted in the highest management teams: "The Office of the Auditor General believes the Ministry of Justice should, to a greater extent, initiate a systematic effort to identify gray areas across ministries, and ask whether there may be gray areas or unclear responsibilities that has not been uncovered. In the Soria Moria Declaration, the government states that it will clarify and map out contingency gray areas" (Royal Ministry of Justice and Police, 2008, p. 17). In report to the Parlament no. 29, 2011-2012, Societal safety, co-operation between agencies who have a role in national societal safety and emergency preparedness has emerged as an important prerequisite for ensuring the best possible use of resources across sectors (The Royal Ministry of Justice and Emergency Preparedness, 2012). This is largely based on the events of July 22, 2011, where we in retrospect had to admit that the cooperation between the involved parties did not work optimally. In the Gjørv Commission's report, examples have been highlighted that poor or lack of communication between operating units led to missed opportunities along the way (NOU 2012: 14, 2012). Based on the theory we have undergone in our bachelor program, as well as information obtained from public inquiries, reports and other available sources, we see that there are some dependencies between the various emergency preparedness agencies that can only be handled through good cooperation. A good understanding of the concept of cooperation, as well as the elements that must be in place to ensure a good cooperation, will therefore be essential for this to work in practice. Methodically, we have chosen to do qualitative surveys, in the form of interviews with key individuals involved in handling a specific accident, namely the Turøy helicopter accident in 2016. Based on media publications, public reports and other open sources, we considered this accident as representative of events where cooperation between land-based and maritime resources have been decisive for optimal results. Our findings may indicate that key factors related to competence, communication, responsibility, cooperation and evaluation are crucial for the effective management of such events. The involved parties must have a good basic competence, which also includes a good knowledge of relevant partners, which in turn facilitate good communication and a clear understanding of accountability and reporting paths that are essential for good cooperation. To end the circle, one must also perform good evaluations and ensure experience recovery, which in turn increases the overall competence and ability to handle similar events

Survival of glioblastoma in relation to tumor location: a statistical tumor atlas of a population-based cohort

Purpose: Previous studies on the effect of tumor location on overall survival in glioblastoma have found conflicting results. Based on statistical maps, we sought to explore the effect of tumor location on overall survival in a population-based cohort of patients with glioblastoma and IDH wild-type astrocytoma WHO grade II–III with radiological necrosis. Methods: Patients were divided into three groups based on overall survival: 24 months. Statistical maps exploring differences in tumor location between these three groups were calculated from pre-treatment magnetic resonance imaging scans. Based on the results, multivariable Cox regression analyses were performed to explore the possible independent effect of centrally located tumors compared to known prognostic factors by use of distance from center of the third ventricle to contrast-enhancing tumor border in centimeters as a continuous variable. Results: A total of 215 patients were included in the statistical maps. Central tumor location (corpus callosum, basal ganglia) was associated with overall survival 24 months. Increased distance from center of the third ventricle to contrast-enhancing tumor border was a positive prognostic factor for survival in elderly patients, but less so in younger patients. Conclusions: Central tumor location was associated with worse prognosis. Distance from center of the third ventricle to contrast-enhancing tumor border may be a pragmatic prognostic factor in elderly patients.publishedVersio

The Long-Term Risk of Knee Arthroplasty in Patients with Arthroscopically Verified Focal Cartilage Lesions: A Linkage Study with the Norwegian Arthroplasty Register, 1999 to 2020

Background: Focal cartilage lesions are common in the knee. The risk of later ipsilateral knee arthroplasty remains unknown. The purposes of the present study were to evaluate the long-term cumulative risk of knee arthroplasty after arthroscopic identification of focal cartilage lesions in the knee, to investigate the risk factors for subsequent knee arthroplasty, and to estimate the subsequent cumulative risk of knee arthroplasty compared with that in the general population. Methods: Patients who had undergone surgical treatment of focal cartilage lesions at 6 major Norwegian hospitals between 1999 and 2012 were identified. The inclusion criteria were an arthroscopically classified focal cartilage lesion in the knee, an age of ≥18 years at the time of surgery, and available preoperative patient-reported outcomes (PROMs). The exclusion criteria were osteoarthritis or “kissing lesions” at the time of surgery. Demographic data, later knee surgery, and PROMs were collected with use of a questionnaire. A Cox regression model was used to adjust for and investigate the impact of risk factors, and Kaplan-Meier analysis was performed to estimate cumulative risk. The risk of knee arthroplasty in the present cohort was compared with that in the age-matched general Norwegian population. Results: Of the 516 patients who were eligible, 322 patients (328 knees) consented to participate. The mean age at the time of the index procedure was 36.8 years, and the mean duration of follow-up was 19.8 years. The 20-year cumulative risk of knee arthroplasty in the cartilage cohort was 19.1% (95% CI, 14.6% to 23.6%). Variables that had an impact on the risk of knee arthroplasty included an ICRS grade of 3 to 4 (hazard ratio [HR], 3.1; 95% CI, 1.1 to 8.7), an age of ≥40 years at time of cartilage surgery (HR, 3.7; 95% CI, 1.8 to 7.7), a BMI of 25 to 29 kg/m2 (HR, 3.9; 95% CI, 1.7 to 9.0), a BMI of ≥30 kg/m2 (HR, 5.9; 95% CI, 2.4 to 14.3) at the time of follow-up, autologous chondrocyte implantation (ACI) at the time of the index procedure (HR, 3.4; 95% CI, 1.0 to 11.4), >1 focal cartilage lesion (HR, 2.1; 95% CI, 1.1 to 3.7), and a high preoperative visual analog scale (VAS) score for pain at the time of the index procedure (HR, 1.1; 95% CI, 1.0 to 1.1). The risk ratio of later knee arthroplasty in the cartilage cohort as compared with the age-matched general Norwegian population was 415.7 (95% CI, 168.8 to 1,023.5) in the 30 to 39-year age group. Conclusions: In the present study, we found that the 20-year cumulative risk of knee arthroplasty after a focal cartilage lesion in the knee was 19%. Deep lesions, higher age at the time of cartilage surgery, high BMI at the time of follow-up, ACI, and >1 cartilage lesion were associated with a higher risk of knee arthroplasty.publishedVersio

Characterisation of HNF1A variants in paediatric diabetes in Norway using functional and clinical investigations to unmask phenotype and monogenic diabetes

Aims/hypothesis Correctly diagnosing MODY is important, as individuals with this diagnosis can discontinue insulin injections; however, many people are misdiagnosed. We aimed to develop a robust approach for determining the pathogenicity of variants of uncertain significance in hepatocyte nuclear factor-1 alpha (HNF1A)-MODY and to obtain an accurate estimate of the prevalence of HNF1A-MODY in paediatric cases of diabetes. Methods We extended our previous screening of the Norwegian Childhood Diabetes Registry by 830 additional samples and comprehensively genotyped HNF1A variants in autoantibody-negative participants using next-generation sequencing. Carriers of pathogenic variants were treated by local healthcare providers, and participants with novel likely pathogenic variants and variants of uncertain significance were enrolled in an investigator-initiated, non-randomised, open-label pilot study (ClinicalTrials.gov registration no. NCT04239586). To identify variants associated with HNF1A-MODY, we functionally characterised their pathogenicity and assessed the carriers’ phenotype and treatment response to sulfonylurea. Results In total, 615 autoantibody-negative participants among 4712 cases of paediatric diabetes underwent genetic sequencing, revealing 19 with HNF1A variants. We identified nine carriers with novel variants classified as variants of uncertain significance or likely to be pathogenic, while the remaining ten participants carried five pathogenic variants previously reported. Of the nine carriers with novel variants, six responded favourably to sulfonylurea. Functional investigations revealed their variants to be dysfunctional and demonstrated a correlation with the resulting phenotype, providing evidence for reclassifying these variants as pathogenic. Conclusions/interpretation Based on this robust classification, we estimate that the prevalence of HNF1A-MODY is 0.3% in paediatric diabetes. Clinical phenotyping is challenging and functional investigations provide a strong complementary line of evidence. We demonstrate here that combining clinical phenotyping with functional protein studies provides a powerful tool to obtain a precise diagnosis of HNF1A-MODY.publishedVersio