Open Reduction Internal Fixation vs Primary Arthrodesis for Displaced Lisfranc Injuries: A Multicenter Randomized Controlled Trial.

BACKGROUND: There is no consensus whether the primary surgical method should be open reduction and internal fixation (ORIF) or primary arthrodesis (PA) for Lisfranc injuries. The aim of our randomized controlled trial was to compare ORIF and PA for displaced Lisfranc injuries. METHODS: This study was a national multicenter randomized controlled trial. Altogether 43 displaced Lisfranc injuries were enrolled in this trial. The primary outcome measure was Visual Analogue Scale Foot and Ankle (VAS-FA) at a 24-months follow-up. The secondary outcome measures were VAS-FA pain, function, and other complaints subscales and the American Orthopaedic Foot & Ankle Society (AOFAS) Midfoot Scale. All outcomes were measured at 6, 12, and 24 months. We were unable to reach the planned sample size of 60 patients; thus, the study remains underpowered. RESULTS: The mean VAS-FA Overall score in the ORIF group was 86.5 (95% CI 77.9, 95.1) and 80.1 (95% CI 72.0, 88.1) in the PA group at the 24-month follow-up. We did not find eligible evidence of a difference in VAS-FA Overall scores (mean between-group difference 6.5 [95% CI -5.3, 18.2], Cohen d = 0.100). CONCLUSION: We did not find evidence of a difference in VAS-FA between ORIF and PA in patients with displaced Lisfranc injuries, and thus both are viable options for the initial surgical method. The trial is underpowered; however, the data may be included in a meta-analysis of similarly designed randomized controlled trials. TRIALS REGISTRATION: ClinicalTrials.gov identifier: NCT02953067 24 October 2016. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

10-year follow-up study on attendance pattern after dental treatment in primary oral health care clinic for fearful patients.

BACKGROUND: Dental fear may lead to avoidance of regular dental treatment. The scope of this long-term practe-based study was to monitor the dental attendance of patients who received chair-side dental and fear treatment. METHODS: In 2000-2006, patients in the City of Oulu, Finland, received treatment for dental fear in the Clinic for Fearful Dental Patients (CFDP) from primary health care dentists trained on this subject. Of the originally treated patients (n = 163), 152 (93%) with sufficient information in dental records made up the study population. Information on their age and sex was available. The number of dental examinations, emergency visits and missed appointments was collected covering the follow-up period of 10 years 2006-2016. For analyses, data were dichotomized according to age at baseline and preliminary outcome baseline condition of dental fear treatment evaluated in 2006. To investigate association further, Poisson regression as well as binary logistic regression models were conducted. As register keeper, the City of Oulu gave permission for this retrospective data-based study. RESULTS: Patients receiving dental fear treatment at younger age (2-10 y) had significantly more dental examinations than those treated at > 10 years. Preliminary success was associated with the number of examinations, but not with emergency visits and missed appointments. Sex was not a significant factor in later dental attendance. There was an association between few dental examinations and dental emergency care need with unsuccessful baseline outcome of dental fear treatment. CONCLUSIONS: Successful dental fear treatment especially at an early age is beneficial for future dental attendance measured by the number of examinations and consequently, less need for emergency care than in the opposite case. Successful fear treatment has positive impact on later dental care and regular dental attendance.

Does the shoe-lace technique aid direct closure of fasciotomy wounds after acute compartment syndrome of the lower leg? A retrospective case-control study.

BACKGROUND AND OBJECTIVE: Tibia fractures are relatively common injuries that are accompanied with acute compartment syndrome in approximately 2% to 20% of cases. Although the shoe-lace technique, where vessel loops are threaded in a crisscross fashion and tightened daily, has been widely used, no studies have compared the shoe-lace technique with the conventional one. The aim of this study was to compare the shoe-lace technique with the conventional technique. METHODS: We identified 359 consecutive patients with intramedullary nailed tibia fracture and complete medical records including outpatient data between April 2007 and April 2015 from electronic patient database of our institute. The use of the shoe-lace technique was compared to conventional one (in which wounds were first left open with moist dressings). Main outcome measurement is direct closure of fasciotomy wounds. RESULTS: From 359 consecutive patients with intramedullary nailed tibia fracture, fasciotomy was performed on 68 (19%) patients. Of these, the shoe-lace technique was used in 47 (69%) patients while in 21 (31%) patients, the shoe-lace technique was not applied. Side-to-side approximation was successful in 36 patients (77%) in the shoe-lace+ group and 7 patients (33%) in the shoe-lace- group (p = 0.002). CONCLUSIONS: The main finding of our comparative study was that the shoe-lace technique seems to ease direct closure of lower leg fasciotomy wounds, and thus reduces the frequency of free skin grafts. Our finding needs to be confirmed in a high-quality randomized controlled trial.

Outcomes after nonoperatively treated non-displaced Lisfranc injury: a retrospective case series of 55 patients.

BACKGROUND: Current knowledge of the role of the nonoperative treatment of Lisfranc injuries is based on a few retrospective case series. Hence, consensus on which patients can be treated nonoperatively does not exist. The aim of this study was to investigate outcomes after nonoperative treatment of Lisfranc injuries. METHODS: In this study, patients were collected by recruiting all computer tomography-confirmed Lisfranc injuries treated during a 5-year period at a major trauma hospital. Between 2 and 6 years after suffering the injury, patients completed the visual analogue scale foot and ankle questionnaire. RESULTS: In total, 55 patients returned adequately completed questionnaires and were included in the study. Of those, 22 patients had avulsion fractures and 33 had simple non-displaced intra-articular fractures. Of these patients, 30 (55%) scored over 90 points in both the pain and function subscales of the VAS-FA, and 35 (64%) scored over 90 points overall. In addition, three (5%) patients scored under 60 points in both the pain and function subscales of the VAS-FA, and four (7%) scored under 60 points overall. Only one patient with avulsion fractures underwent secondary surgery. CONCLUSION: Nonoperative treatment has a role in the treatment of Lisfranc injuries, and the results of our study support the view that avulsion and simple intra-articular fractures with < 2 mm of displacement can be treated nonoperatively with high functional outcomes. The results of nonoperative and operative treatment should be compared in a prospective randomized controlled study setting in future studies. LEVEL OF EVIDENCE: IV, retrospective case series.

Inter- and intraobserver reliability of non-weight-bearing foot radiographs compared with CT in Lisfranc injuries.

BACKGROUND: Injury of the tarsometatarsal (TMT) joint complex, known as Lisfranc injury, covers a wide range of injuries from subtle ligamentous injuries to severely displaced crush injuries. Although it is known that these injuries are commonly missed, the literature on the accuracy of the diagnostics is limited. The diagnostic accuracy of non-weight-bearing radiography (inter- or intraobserver reliability), however, has not previously been assessed among patients with Lisfranc injury. METHODS: One hundred sets of foot radiographs acquired due to acute foot injury were collected and anonymised. The diagnosis of these patients was confirmed with a CT scan. In one-third of the radiographs, there was no Lisfranc injury; in one-third, a nondisplaced (< 2 mm) injury; and in one-third, a displaced injury. The radiographs were assessed independently by three senior orthopaedic surgeons and three orthopaedic surgery residents. RESULTS: Fleiss kappa (κ) coefficient for interobserver reliability resulted in moderate correlation κ = 0.50 (95% CI: 0.45- 0.55) (first evaluation) and κ = 0.58 (95% CI: 0.52-0.63) (second evaluation). After three months, the evaluation was repeated and the Cohen's kappa (κ) coefficient for intraobserver reliability showed substantial correlation κ = 0.71 (from 0.64 to 0.85). The mean (range) sensitivity was 76.1% (60.6-92.4) and specificity was 85.3% (52.9-100). The sensitivity of subtle injuries was lower than severe injuries (65.4% vs 87.1% p = 0.003). CONCLUSIONS: Diagnosis of Lisfranc injury based on non-weight-bearing radiographs has moderate agreement between observers and substantial agreement between the same observer in different moments. A substantial number (24%) of injuries are missed if only non-weight-bearing radiographs are used. Nondisplaced injuries were more commonly missed than displaced injuries, and therefore, special caution should be used when the clinical signs are subtle. LEVEL OF EVIDENCE: III.

Incidence of hallux valgus primary surgical treatment. Finnish nationwide data from 1997 to 2014.

BACKGROUND: Many surgical procedures have been described for hallux valgus. Evidence provided by the current literature on the different procedures is, however, poor. The purpose of this study was to assess the incidence of HV surgery in Finland between 1997 and 2014 and to find out whether changes in operation techniques of HV have occurred during the study period. METHODS: The study included all adult patients (≥18 years) who underwent primary HV operation. Patients were included into study if they had been operated with a diagnosis of HV (ICD-10 code M20.1). The data were collected by the Finnish National Hospital Discharge Register (NHDR). RESULTS: The total incidence of primary HV operations was 66.7 per 100,000 person-years in 1997 and 41.4 per 100,000 person-years in 2014. The incidence of arthroplasty operations of the MTP-1 joint decreased while at the same time the incidence of the MTP-1 joint arthrodesis and TMT-1 arthrodesis increased. The gender difference (13% men, 87% women) is consistent with previous studies. CONCLUSION: This study shows a significant decreasing trend of HV operations in Finland between 1997 and 2014. During the study period, the incidence of MTP I joint arthroplasty decreased, and since 2005 the incidence of MT-1-osteotomies has almost halved. At the same time, the incidence of MTP-1 joint arthrodesis increased by over 1000% and TMT-1 joint arthrodesis by nearly 2000%.

Three week versus six week immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-inferiority clinical trial.

OBJECTIVE: To determine whether treatment of isolated stable Weber B type ankle fractures with a cast or a simple orthotic device for three weeks produces non-inferior outcomes compared with conventional immobilisation in a cast for six weeks. DESIGN: Randomised, pragmatic, non-inferiority, clinical trial with blinded outcome assessment. SETTING: Two major trauma centres in Finland, 22 December 2012 to 6 June 2016. PARTICIPANTS: 247 skeletally mature patients aged 16 years or older with an isolated Weber B type fibula fracture and congruent ankle mortise in static ankle radiographs. INTERVENTIONS: Participants were randomly allocated to conventional six week cast immobilisation (n=84) or three week treatment either in a cast (n=83) or in a simple orthosis (n=80). MAIN OUTCOME MEASURES: The primary, non-inferiority, intention-to-treat outcome was the Olerud-Molander Ankle Score at 12 months (OMAS; range 0-100; higher scores indicate better outcomes and fewer symptoms). The predefined non-inferiority margin for the primary outcome was -8.8 points. Secondary outcomes were ankle function, pain, quality of life, ankle motion, and radiographic outcome. Follow-up assessments were performed at 6, 12, and 52 weeks. RESULTS: 212 of 247 randomised participants (86%) completed the study. At 52 weeks, the mean OMAS was 87.6 (SD 18.3) in the six week cast group, 91.7 (SD 12.9) in the three week cast group, and 89.8 (SD 18.4) in the three week orthosis group. The between group difference at 52 weeks for the three week cast versus six week cast was 3.6 points (95% confidence interval -1.9 to 9.1, P=0.20), and for the three week orthosis versus six week cast was 1.7 points (-4.0 to 7.3, P=0.56). In both comparisons, the confidence intervals did not include the predefined inferiority margin of -8.8 points. The only statistically significant between group differences observed in the secondary outcomes and harms in the two primary comparisons were slight improvement in ankle plantar flexion and incidence of deep vein thrombosis, both in the three week orthosis group versus six week cast group. CONCLUSION: Immobilisation for three weeks with a cast or orthosis was non-inferior to conventional cast immobilisation for six weeks in the treatment of an isolated stable Weber B type fracture. TRIAL REGISTRATION: ClinicalTrials.gov NCT01758835.

Incidence and Characteristics of Midfoot Injuries.

BACKGROUND:: The epidemiology of midfoot injuries is poorly known. It has been estimated that the incidence of Lisfranc injuries (intra-articular injury in the tarsometatarsal joint) is 1/55 000 person-years and the incidence of Chopart injuries (intra-articular injury in the talonavicular and calcaneocuboidal joint) 4/100 000 person-years. The purpose of our study was to assess the computed tomography (CT) imaging-based incidence (per 100 000 person-years) and trauma mechanisms of midfoot injuries. METHODS:: All CT studies performed due to acute injury of the foot and ankle region between January 1, 2012, and December 31, 2016, at Tampere University Hospital were reviewed. Patients presenting with an injury in the midfoot region in the CT scan were included in this study, and their records were retrospectively evaluated to assess patient characteristics. RESULTS:: During the 5-year study period, 953 foot and ankle CT scans were obtained because of an acute injury of the foot and ankle. Altogether, 464 foot injuries were found. Of these, 307 affected the midfoot area: 233 (75.9%) the Lisfranc joint area, 56 (18.2%) the Chopart joint area, and 18 (5.9%) were combined injuries or miscellaneous injuries in the midfoot. The incidence of all midfoot injuries was 12.1/100 000 person-years. The incidence of Lisfranc injuries was 9.2/100 000 person-years. The incidence of Chopart injuries was 2.2/100 000 person-years. CONCLUSIONS:: The incidence of Lisfranc injuries was higher and the incidence of Chopart injuries lower than previously estimated. More than two-thirds of the midfoot injuries in this study were nondisplaced (<2 mm displacement in fracture or joint) and were caused by low-energy trauma. LEVEL OF EVIDENCE:: Level III, epidemiologic study.

Nonoperative, open reduction and internal fixation or primary arthrodesis in the treatment of Lisfranc injuries: a prospective, randomized, multicenter trial - study protocol.

BACKGROUND: Lisfranc injuries are known to be rare and often overlooked injuries that can cause long-term disability and pain when missed or treated incorrectly. The wide variety of Lisfranc injuries ranges from subtle ligament distensions to open fracture dislocations. The treatment of Lisfranc joint injuries is still controversial and very little is known about what types of injury can be treated nonoperatively. The current literature provides only two randomized studies on dislocated Lisfranc injuries. These studies have shown that primary arthrodesis (PA) leads to a similar or better outcome and results in fewer secondary operations when compared with open reduction and internal fixation (ORIF) in ligamentous injuries. There have been no previous randomized studies of the nonoperative versus operative treatment of Lisfranc injuries. Therefore, the purpose of this study is to compare the operative and nonoperative treatment of non-dislocated Lisfranc injuries and to compare the ORIF and PA treatment of dislocated Lisfranc injuries. METHODS: This study is a prospective, randomized, national multi-center trial. The trial comprises two strata: Stratum I compares cast-immobilization versus open reduction and internal fixation (ORIF) treatment of non-dislocated Lisfranc joint injuries. Stratum II compares PA versus ORIF in the treatment of dislocated injuries of the Lisfranc joint. The main hypothesis of stratum I is that the nonoperative treatment of non-dislocated Lisfranc injuries achieves a similar outcome compared with operative treatment (ORIF). The hypothesis of stratum II is that PA of dislocated Lisfranc injuries yields a similar functional outcome compared with ORIF, but that PA results in fewer secondary operations than ORIF. The main outcome measure is the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot score and the secondary outcome measures are Visual-Analogue-Scale Foot and Ankle (VAS-FA), Visual-Analogue-Scale (VAS), rate of secondary operations and other treatment-related complications. The results will be analyzed after the 2-year follow-up period. DISCUSSION: This publication presents a prospective, randomized, national multi-center trial study protocol. It provides details of patient flow, randomization, aftercare and methods of analysis of the material and ways to present and publish the results. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02953067 24.10.2016.

Treatment of acute Achilles tendon rupture with a standardised protocol.

INTRODUCTION: A treatment protocol favouring non-operative treatment and based on early weight-bearing and early range-of-motion exercises was implemented in standard clinical care of a level I trauma clinic. MATERIALS AND METHODS: All patients treated due to acute Achilles tendon rupture between 2008 and 2014 were included in the study (n = 411). The patient records were retrospectively evaluated. RESULTS: The mean age of patients was 47 (range 17-88) years. In total, 213 (52%) acute Achilles tendon ruptures were treated operatively and 198 (48%) non-operatively. The annual proportion of operatively treated patients declined from 70 to 21% during the study period. The traumatic re-rupture rate was similar between the operative (4%) and the non-operative (6%) treatment groups (p = 0.385), even though the patients in the non-operative group were significantly older and had more co-morbidities than the operatively treated patients. Of the operatively treated patients, 10% (n = 21) had wound healing problems. In 6/198 patients, the non-operative treatment had to be converted to surgical treatment in the early phase. Unsatisfactory functional outcome after the treatment was reported in 7/213 patients in the operative and 10/198 in the non-operative group (p = 0.234). CONCLUSIONS: Our study showed that it is possible to implement a standardised treatment protocol to guide the decision-making and treatment and of an acute Achilles tendon rupture as a part of the daily care in a large standard trauma hospital. The clinical outcome and the rate of complications were fully comparable to the good clinical results achieved in RCT-study settings despite the heterogeneity of the treated patients and non-specialisation of the medical staff, showing that the protocol could find the most reasonable treatment for each patient and reduced dramatically the rate of operative treatment. LEVEL OF EVIDENCE: Level III, comparative series.

Epidemiology of calcaneal fractures in Finland.

BACKGROUND: The purpose of this study was to assess the nationwide incidence (per 100,000 person-years) of operative treatment and hospitalization due to calcaneal fractures (CF) in Finland. METHODS: The study was based on the Finnish National Hospital Discharge Register. All patients aged 18-years or older admitted to Finnish hospitals for primary treatment of CF in 1987-2012 were included. RESULTS: During the 26-year study period 5977 patients were hospitalized with main or secondary diagnosis of a CF. The incidence of hospitalization due to CF remained relatively stable: (12.5)/100,000 in men and 3.9/100,000 in women. The men were younger (median 43 years) than the women (median 61 years). CONCLUSIONS: The incidence of the hospitalization due to CF in Finland has remained at steady level during the past 26 years. The incidence of CF is three times higher in men. In 2012 22% of the fractures were operatively treated.

Re-organizing inpatient care saves legs in patients with diabetic foot infections.

AIMS: In this study, we evaluated the effects of the re-organization of inpatient care for patients with a diabetic foot infection, and the implementation of a specialized multi-disciplinary wound department at an academic tertiary hospital. METHODS: This was a retrospective cohort study, comprising 272 patients treated for diabetic foot infections in 2006-2007 (Group 1, n=124) and 2013-2014 (Group 2, n=148). In 2012, inpatient care of all chronic wounds was centralized at a single wound department with a multi-disciplinary team. We assessed group outcome before and after the re-organization. RESULTS: During the 7-year study period, the incidence of hospitalized patients with a diabetic foot infection increased 19%. After initiating the re-organization, the below-the-knee amputation rate was significantly reduced (25.8% vs. 9.5%, p<0.001). The median time from admission to surgical intervention decreased from 5days to 2days, p<0.001. The length of hospitalization also tended to decrease after the reorganization. CONCLUSIONS: The findings of this study demonstrate the benefits of treating diabetic foot infections at a specialized wound department with a multi-disciplinary team. The benefits were achieved by simply distributing the workload and organizing schedules, without new investments or additional personnel. The findings of this study indicate that patients with diabetic foot infections present a challenge that is beyond the expertise of a single field of medicine. A working collaboration between disciplines and a specialized wound department are central in achieving better results.

The Elimination of Transfer Distances Is an Important Part of Hospital Design.

OBJECTIVE: The objective of the present study was to describe how a specific patient flow analysis with from-to charts can be used in hospital design and layout planning. BACKGROUND: As part of a large renewal project at a university hospital, a detailed patient flow analysis was applied to planning the musculoskeletal surgery unit (orthopedics and traumatology, hand surgery, and plastic surgery). METHOD: First, the main activities of the unit were determined. Next, the routes of all patients treated over the course of 1 year were studied, and their physical movements in the current hospital were calculated. An ideal layout of the new hospital was then generated to minimize transfer distances by placing the main activities with close to each other, according to the patient flow analysis. The actual architectural design was based on the ideal layout plan. Finally, we compared the current transfer distances to the distances patients will move in the new hospital. RESULTS: The methods enabled us to estimate an approximate 50% reduction in transfer distances for inpatients (from 3,100 km/year to 1,600 km/year) and 30% reduction for outpatients (from 2,100 km/year to 1,400 km/year). CONCLUSIONS: Patient transfers are nonvalue-added activities. This study demonstrates that a detailed patient flow analysis with from-to charts can substantially shorten transfer distances, thereby minimizing extraneous patient and personnel movements. This reduction supports productivity improvement, cross-professional teamwork, and patient safety by placing all patient flow activities close to each other. Thus, this method is a valuable additional tool in hospital design.

Hypertrophy of the flexor hallucis longus muscle after tendon transfer in patients with chronic Achilles tendon rupture.

BACKGROUND: Flexor hallucis longus tendon (FHLT) transfer has become a popular method for reconstructing a chronic Achilles tendon rupture (ATR). The purpose of this study was to evaluate the clinical outcomes and possible hypertrophy of the FHL muscle after FHLT transfer in patients with chronic ATR. METHODS: Seven patients with chronic ATR underwent an FHLT transfer to heel through single incision. The patients were clinically evaluated 27 (16-39) months after the surgery. The patient satisfaction was assessed with Achilles Tendon Total Rupture Scale (ATRS). Isokinetic strength was measured from both legs. The FHL muscle hypertrophy was evaluated from MRI of both legs. All subjects also performed a gait analysis with an instrumented walkway system (GAITRite(®)). RESULTS: The plantar flexion strength was 16.1% (-45, 7-2, 4%) weaker in the operated leg. ATRS scores averaged 70.3. Marked hypertrophy, +52% (9-104%) of the FHL muscle was seen in the operated leg compared to the non-operated leg. The gait analysis did not show any marked pathology in any of the patients. CONCLUSIONS: A mean hypertrophy of 52% of the FHL muscle was found after FHLT transfer for the chronic ATR. This indicates strong adaptation capacity of this muscle after FLHT transfer in situation where the function of the gastro-soleus complex was severely impaired preoperatively. The reconstruction of chronic ATR with FHLT transfer provided a good functional outcome and excellent patient satisfaction.

[Pressure ulcer and tetanus in an elderly person]. / Vanhuksen painehaava ja jäiykkäkouristus.

Clostridium tetani, the bacterium causing tetanus, can be found both in the soil and intestinal normal flora. While the majority of the Finnish population has adequate vaccination protection, part of the population exhibits weakened protection. We describe a case in which a patient developed tetanus as a consequence of pressure ulcer. The symptoms extended to the respiratory muscle region, resulting in respiratory insufficiency and cardiac arrest for the patient. The patient, however, recovered after successful resuscitation and extended intensive care as required by tetanus.

Effect of immobilization, off-loading and zoledronic acid on bone mineral density in patients with acute Charcot neuroarthropathy: a prospective randomized trial.

BACKGROUND: Bisphosphonates are commonly used as an adjuvant in the management of acute Charcot neuroarthropathy (CNA), although the clinical efficacy of the treatment is controversial. The aim of the present study is to investigate the effect of immobilization and zoledronic acid on bone mineral density (BMD) changes during the treatment of acute CNA. METHODS: Thirty-five patients with acute midfoot CNA were randomly assigned to treatment with either zolendronic acid or placebo. BMD of the lumbar spine and both hips was measured at baseline and after six months of treatment. RESULTS: Comparison between BMD at presentation and at 6 months demonstrated a significant fall in BMD in the placebo group at the CNA-affected femoral neck (-3.2%, p=0.016) and in the CNA-free hip (-1.2%, p=0.026). Conversely, a significant rise in BMD was observed in the zolendronic acid group at all measured areas of the CNA-free hip. DISCUSSION AND CONCLUSIONS: Immobilization and off-loading does not lead to marked disuse osteoporosis in patients with acute CNA after 6 months of treatment. Treatment with zoledronic acid led to a statistically significant increase in hip BMD compared to placebo.

Lisfranc injury in adolescents.

BACKGROUND: There are only few studies of Lisfranc injuries in children and adolescents. The aim of this study was to evaluate the mid-term results of the operatively treated injuries. METHODS: Seven Lisfranc injuries of adolescents were treated operatively in the Tampere University Hospital between 2004 and 2009. In four of the seven feet, the trauma comprised all the metatarsal bones. All patients were treated with open reduction and internal fixation. A questionnaire concerning the function and pain of the foot was sent to all the patients. RESULTS: In all but one case, the anatomical reduction was achieved and held during the follow-up. However, most patients claimed discomfort or constant harm in the injured foot at the end of the follow-up. Still, all the patients were able to run and no one needed to wear special shoes or any other kind of means. CONCLUSIONS: Lisfranc injuries in adolescents are likely to cause constant harm, even if the anatomical reduction is achieved.

[When is ankle fracture treatable without surgery?]. / Milloin nilkkamurtuman voi hoitaa ilman leikkausta? Stabiiliuteen perustuva nilkkamurtumaluokitus.

Stability of a fractured ankle is the most important factor when considering the choice between operative and non-operative treatment. Depending on the mechanism of injury, the most common type of ankle fracture, spiral fracture of the lateral malleolus (Weber B) may be stable or unstable. It can be treated conservatively, provided that the shape of the ankle joint has remained intact in both projections and there is neither significant injury of deep deltoid ligament nor another fracture within the ankle region. In cases of suspected unstable ankle fracture the patients should be referred to a clinic having experience of surgical therapy of ankle fractures.

[Acute methemoglobinemia in a young girl]. / Nuoren tytön hengitysvaikeus ja lääkeaineen aiheuttama methemoglobinemia.

Methemoglobinemia is an acute and potentially life-threatening condition. It can be congenital but more often acquired. Suspected the diagnosis of this condition is straight forward. In methemoglobinemia red cells are unable to carry oxygen, because the iron of the heme is oxidised from Fe2+ to Fe3+. Symptoms are depended on the level of methemoglobinemia. Intravenous methylene blue is the treatment of choice.

[Ankle ligament injury: diagnosis and functional therapy]. / Nilkan ligamenttivamman diagnostiikka ja funktionaalinen hoito.

Primary treatment of acute ankle ligament injury is almost always conservative. The more severe injury is, the more careful initial treatment, rehabilitation and follow-up is required. If the rupture of ligaments is suspected, the ankle must be supported with an air splint or ankle support. Functional therapy is initiated immediately upon the occurrence of the injury. Independent training by the patient is the cornerstone of functional therapy. Persistence of symptoms or recurrent injuries are often due to inadequate rehabilitation.