Regional variation in low-value musculoskeletal surgery: a nationwide study from the Finnish Care Register.

BACKGROUND AND PURPOSE:  Healthcare systems globally are grappling with resource constraints and rising costs. Concerns have been raised about "low-value" care, which consumes healthcare resources without benefiting patients. We aimed to examine regional differences in common low-value musculoskeletal surgeries in Finland and explore explanatory factors behind the variation. METHODS:  Using data from the Finnish Care Register for Health Care, surgeries conducted from 2006-2007 compared with 2020-2021 were analyzed across 20 hospital districts. Selected surgeries (acromioplasty, rotator cuff repair, partial meniscectomy, wrist arthroscopy, ankle arthroscopy, and distal radius fracture fixation) were categorized based on NOMESCO procedure codes, and incidence rates in older populations were calculated based on population size derived from Statistics Finland. RESULTS:  We found substantial regional disparities in low-value surgeries. The incidence rates were higher in hospitals with high historical incidence rates and smaller population sizes, suggesting that the uptake of evidence is slower in small non-academic hospitals. CONCLUSION:  The incidence of low-value surgery is declining but regional differences remain large. It is unlikely that regional variation in disease incidence explains such large variation in low-value surgery. Instead, local treatment culture seems to be the driving force behind low-value surgery, and the practices seem to be more entrenched in small hospitals.

The Influence of Adolescent health-related Behaviors on Degenerative Low Back Pain Hospitalizations and Surgeries in Adulthood: A Longitudinal Study.

STUDY DESIGN: Retrospective longitudinal study. OBJECTIVE: This study aims to investigate the influence of adolescent health-related behaviors (physical activity, high BMI, drunkenness, smoking), self-reported chronic disease, and low socioeconomic status (SES) on the development of low back pain requiring hospitalization or surgery. SUMMARY OF BACKGROUND DATA: The baseline data were surveys gathered biennially in 1981-1997 (the Adolescent Health and Lifestyle Survey) and individually linked with outcome data, degenerative low back pain hospitalizations, and spine surgeries retrieved from the Care Register for Health Care. A total of 47 724 participants were included. Explanatory variables included physical activity, high BMI, smoking, monthly drunkenness, chronic diseases, and family SES. METHODS: A logistic regression model was used to analyze the influence of adolescent health-related behaviors (physical activity, high BMI, drunkenness, smoking), self-reported chronic disease, and low socioeconomic status (SES) on degenerative low back pain hospitalization, lumbar disc herniation (LDH) hospitalization and/or spine surgery. Covariates were selected using directed acyclic graphs (DAGs). RESULTS: A total of 5538 participants had degenerative low back pain hospitalizations, 2104 had LDH hospitalizations, and 913 had spinal surgery over an average of 27-years follow-up. High BMI (aOR 1.25, CI 1.12-1.38), smoking (aOR 1.53, CI 1.43-1.62), monthly drunkenness (aOR 1.17, CI 1.10-1.26), and chronic diseases (aOR 1.47, CI 1.35-1.61) in adolescence increased the odds of hospitalizations during follow-up. In addition, high BMI (aOR 1.37, CI 1.09-1.72), smoking (aOR 1.40, CI 1.21-1.61), and monthly drunkenness (aOR 1.19, CI 1.01-1.39) increased the odds of spine surgeries. CONCLUSIONS: We found that smoking, high BMI, monthly drunkenness, chronic diseases, and low family SES in adolescence increased the likelihood of degenerative low back pain hospitalizations in adulthood. In addition, high BMI, smoking, and monthly drunkenness in adolescence increased the odds of spinal surgeries.

Paediatric traumatic brain injury and attention-deficit/hyperactivity disorder medication in Finland: a nationwide register-based cohort study.

BACKGROUND: The association between paediatric traumatic brain injury (pTBI) and post-traumatic attention-deficit/hyperactivity disorder (ADHD) medication usage remains understudied subject. OBJECTIVE: We aimed to evaluate the association between pTBI and subsequent ADHD medication. METHODS: A nationwide retrospective cohort study in Finland from 1998 to 2018 included 66 594 patients with pTBI and 61 412 references with distal extremity fractures. ADHD medication data were obtained from the Finnish Social Insurance Institution. The primary outcome was post-traumatic pediatric ADHD medication. A 1-year washout period was applied, and follow-up started 1 year post-pTBI. FINDINGS: Kaplan-Meier analyses showed higher ADHD medication usage in patients with pTBI, especially post-operatively. Both sex groups exhibited elevated rates compared with the reference group. Over 10 years, cumulative incidence rates were 3.89% (pTBI) vs 1.90% (reference). HR for pTBI was 1.89 (95% CI 1.70 to 2.10) after 4 years and 6.31 (95% CI 2.80 to 14.20) for the operative group after the initial follow-up year. After 10 years, cumulative incidence in females increased to 2.14% (pTBI) vs 1.07% (reference), and in males, to 5.02% (pTBI) vs 2.35% (reference). HR for pTBI was 2.01 (95% CI 1.72 to 2.35) in females and 2.23 (95% CI 2.04 to 2.45) in males over 1-20 years. CONCLUSIONS: A substantial association between pTBI and post-traumatic ADHD medication was evidenced over a 20-year follow-up period. CLINICAL IMPLICATIONS: These results stress the need for preventive measures for pTBI and highlight the potential impact of long-term post-traumatic monitoring and psychoeducation.

Fear of Childbirth After Major Orthopedic Traumas: A Nationwide Multi-Register Analysis.

BACKGROUND: The aim of this study was to evaluate the association between previous major traumas and the prevalence of fear of childbirth (FOC) and the subsequent effects of FOC on the intended mode of delivery. METHODS: In this nationwide retrospective register-based cohort study, data from the Care Register for Health Care were linked with the National Medical Birth Register (MBR) to evaluate the prevalence of FOC after major traumas. A total of 18,573 pregnancies met the inclusion criteria. A multivariable logistic regression model was used to assess the effects of FOC on the intended mode of delivery. Women with major traumas before pregnancy were compared to individuals with wrist fractures. Adjusted odds ratios (aORs) with 95% CIs between the groups were compared. RESULTS: Of those pregnancies that occurred after major traumas, 785 (6.2%) women were diagnosed with FOC after traumatic brain injury (TBI), 111 (6.1%) women after spine fracture, 38 (5.0%) women after pelvic fracture, 22 (3.2%) women after hip or thigh fracture, and 399 (5.2%) women in the control group. Among those women diagnosed with FOC, the adjusted odds for elective CB as an intended mode of delivery were highest among women with previous spine fractures (aOR 2.28, CI 1.45-3.60) when compared to the control group. CONCLUSIONS: We found no evidence of differences in maternal FOC in patients with preceding major traumas when compared to the control group. Therefore, it seems highly likely that the major trauma itself is the explanatory factor for the increased rate of elective CB.

Medial patellofemoral ligament injury. Location-based rate of recurrent patellar dislocation after non-operative treatment.

OBJECTIVES: The role of the medial patellofemoral ligament (MPFL) as a patellofemoral joint stabilizing structure is undisputable. After traumatic patellar dislocation, MPFL injury, together with bone edema in the medial patellar facet and lateral femoral condyle, is a pathognomonic finding in magnetic resonance imaging (MRI). MPFL injury in the femoral insertion has been reported to most likely predict recurrent dislocations. The objective of this study was to detect if any MPFL injury location predicts the earliest onset of the patellar re-dislocation. METHODS: In total, 64 eligible patients with a first-time traumatic patellar dislocation were recruited to the trial. The diagnosis was confirmed within 3 weeks with 3T magnetic resonance imaging. The location of the MPFL injury in MRI was localized at the patellar insertion, midsubstance area, femoral insertion, or a combination of these. During the three-year follow-up period, patellar re-dislocations, range of motion, quadriceps muscle atrophy, and daily symptoms were determined. All the patients were treated non-operatively. RESULTS: Out of 64 patients, 33 (51.6%) had at least one episode of patellar re-dislocation. Re-dislocations occurred in 8 out of 25 (32.0%) patients with the main injury at the femoral insertion, 5 out of 15 (33.3%) patients with the main injury at the midsubstance area, and 10 out of 24 (41.7%) patients with the main injury at the patellar insertion during the 36 months follow-up (p â€‹= â€‹0.758). According to Kaplan-Meier analysis, the location of MPFL injury did not have any statistically significant effect on the timing of re-dislocations. At 36 months, survival of patients with MPFL injury at the patellar insertion was 70.8%, which was not statistically significantly different than the survival in patients with injury at the femoral insertion (88.0%) or at the midsubstance area (93.3%). No differences between single and multiple MPFL injuries were found. At 4 weeks, the range of motion was more restricted in patients with MPFL injury at the femoral insertion (93.4° vs. 108.0° for injury at the midsubstance area and 107.7° at the patellar insertion). CONCLUSION: The location of MPFL injury did not have any statistically significant effect on timing or the rate of re-dislocations. The MPFL injury at the femoral insertion predicts decreased range of motion (ROM) of the knee and increased quadriceps muscle atrophy during the first three months after sustaining injury. LEVEL OF EVIDENCE: Level III.

Cone-beam computed tomography imaging and three-dimensional analysis of midfoot joints during non-weightbearing and weightbearing in 11 healthy feet.

BACKGROUND: Studies report that Lisfranc injury is more common than thought. Several imaging methods for assessing the stability of Lisfranc injury have been described but many are impossible to standardize and not accurate enough. PURPOSE: To present a three-dimensional (3D) method for analyzing the changes in the joint space width of the midfoot joint and the joints of the medial part of the Lisfranc complex in healthy individuals. MATERIAL AND METHODS: Non-weightbearing and weightbearing cone-beam computed tomography (CBCT) images of 11 healthy feet were acquired and analyzed with 3D software. The mean range of joint space width changes of each joint was computed from the changes in individual image pairs. RESULTS: 3D analysis software was used to analyze the medial part of the Lisfranc complex. In this sample of healthy feet, the changes in the joint spaces in the medial part of Lisfranc complex, calculated with 3D analysis software, was less than 0.6 mm. The distance between bones increased or decreased, depending on which part of the joint surface the measurements were taken. CONCLUSION: In this study, we present a 3D analysis method to evaluate midfoot joint space width changes. Our analysis revealed that in healthy feet there are only minimal changes in the joint space width between weightbearing and non-weightbearing indicating minimal movement of the midtarsal joints. The 3D analysis of weightbearing CBCT data provides a promising tool for analyzing the small midfoot joints in a variety of conditions.

Effect of accelerated postoperative rehabilitation after tibial tubercle distalisation: A randomised controlled trial protocol.

Patella alta is a clinical condition where the patella is positioned too proximal in relation to the femoral trochlea. Such an abnormality may cause patellar instability and predispose to recurrent patellofemoral dislocations and patellofemoral pain. There are no conclusive guidelines for determining a threshold for too high positioned patella, as several different methods have been described to measure patellar height. As a surgical solution, distalising tibial tubercle osteotomy has been described to correct excessive patellar height. In the early phase of the distalising tibial tubercle osteotomy postoperative protocol, weightbearing and knee flexion are limited with a brace commonly for 4-8 weeks to avoid potential implant failure leading to displacement of the osteotomy or non-union. The potential risks for adverse effects associated with the limitation rehabilitation protocol include a delay in regaining knee range of motion, stiffness and muscle weakness. As a result, recovery from surgery is delayed and may lead to additional procedures and long-term morbidity in knee function. This is a prospective, randomised, controlled, single-blinded, single centre trial comparing a novel accelerated rehabilitation protocol with the traditional, motion restricting rehabilitation protocol. All skeletally mature patients aged 35 years and younger, referred to as the distalising tibial tubercle osteotomy procedure group, are eligible for inclusion in the study. Patients will be randomised to either the fast rehabilitation group or the traditional rehabilitation group. Patients with patellar instability will be additionally treated with medial patellofemoral ligament reconstruction. The hypothesis of the trial is that the novel accelerated rehabilitation protocol will lead to faster recovery and improved functional outcome at 6, 12 and 24 weeks compared with the conservative rehabilitation protocol. A secondary hypothesis is that the complication rate will be similar in both groups. The study will document short-term recovery and the planned follow-up will be 3 years. After the 1-year follow-up, the trial results will be disseminated in a major peer-reviewed orthopaedic publication. Protocol version 3.6, date 28/11/2023.

Health-Related Quality of Life in severely injured patients in Finland: an observational cohort study of 325 patients with 1-year follow-up.

BACKGROUND: Major trauma has a significant effect on Health-Related Quality of Life (HR-QoL). It is unclear, however, which factors most affect HR-QoL. This study aims to evaluate HR-QoL after severe injury in Finland and determine how different injury patterns and patient-related factors, such as level of education and socioeconomic group, are associated with HR-QoL. We also assess how well different injury scoring systems associate with HR-QoL. METHODS: We retrospectively analyzed 325 severely injured trauma patients (aged ≥ 18 years, New Injury Severity Score, (NISS) ≥ 16, and alive at 1 year after injury) treated in the Intensive Care Unit (ICU) or High Dependence Unit (HDU) of Tampere University Hospital (TAUH) from 2013 through 2016. HR-QoL was assessed with the EQ-5D-3L questionnaire completed during ICU stay and 1 year after injury. HR-QOL index values and reported problems were further compared with Finnish population norms. RESULTS: The severity of the injury (measured by ISS and NISS) had no significant association with the decrease in HR-QoL. Length of ICU stay had a weak negative correlation with post-injury HR-QoL and a weak positive correlation with the change in HR-QoL. The largest mean decrease in HR-QoL occurred in patients with spinal cord injury (Spine AIS ≥ 4) (-0.338 (SD 0.136)), spine injury in general (Spine AIS ≥ 2 (-0.201 (SD 0.279)), and a lower level of education (-0.157 (SD 0.231)). Patient's age, sex, or socioeconomic status did not seem to associate with smaller or greater changes in HR-QoL. CONCLUSIONS: After serious injury, many patients have permanent disabilities which reduce HR-QoL. Injury scoring systems intended for assessing the risk for death did not seem to associate with HR-QoL and are not, therefore, a meaningful way to predict the future HR-QoL of a severely injured patient. Recovery from the injury seems to be weaker in poorer educated patients and patients with spinal cord injury, and these patients may benefit from targeted additional measures. Although there were significant differences in baseline HR-QoL levels between different socioeconomic groups, recovery from injury appears to be similar, which is likely due to equal access to high-quality trauma care.

Cumulative costs of severe traffic injuries in Finland: a 2-year retrospective observational study of 252 patients.

Road traffic injuries cause considerable financial strain on health care systems worldwide. We retrospectively analyzed injury-related costs of 252 severely injured (New Injury Severity Score, NISS ≥ 16) patients treated at Tampere University Hospital (TAUH) between 2013 and 2017, with 2-year follow-up. The costs were divided into direct treatment, indirect costs, and other costs. We analyzed various injury- and patient-related factors with costs. The total costs during the 2-year study period were 20 million euros. Median cost was 41,202 euros (Q1 23,409 euros, Q3 97,726 euros), ranging from 2,753 euros to 549,787 euros. The majority of costs (69.1%) were direct treatment costs, followed by indirect costs (28.4%). Other costs were small (5.4%). Treatment costs increased with the severity of the injury or when the injury affected the lower extremities or the face. Indirect costs were higher in working age patients and in patients with a higher level of education. The relative proportions of direct and indirect costs were constant regardless of the amount of the total costs. The largest share of costs was caused by a relatively small proportion of high-cost patients during the 1st year after injury. Combined, this makes planning of resource use challenging and calls for further studies to further identify factors for highest costs.

Impact of childhood traumatic brain injury on fitness for service class, length of service period, and cognitive performance during military service in Finland from 1998 to 2018: A retrospective register-based nationwide cohort study.

INTRODUCTION: Traumatic brain injury (TBI) can cause neuronal damage and cerebrovascular dysfunction, leading to acute brain dysfunction and considerable physical and mental impairment long after initial injury. Our goal was to assess the impact of pediatric TBI (pTBI) on military service, completed by 65-70% of men in Finland. METHODS: We conducted a retrospective register-based nationwide cohort study. All patients aged 0 to 17 years at the time of TBI, between 1998 and 2018, were included. Operatively and conservatively treated patients with pTBI were analyzed separately. The reference group was comprised of individuals with upper and lower extremity fractures. Information on length of service time, service completion, fitness for service class, and cognitive performance in a basic cognitive test (b-test) was gathered from the Finnish Military Records for both groups. Linear and logistic regression with 95% CI were used in comparisons. RESULTS: Our study group comprised 12 281 patients with pTBI and 20 338 reference group patients who participated in conscription. A total of 8 507 (66.5%) men in the pTBI group and 14 953 (71.2%) men in the reference group completed military service during the follow-up period. Men in the reference group were more likely to complete military service (OR 1.26, CI 1.18-1.34). A total of 31 (23.3%) men with operatively treated pTBI completed the military service. Men with conservatively treated pTBI had a much higher service rate (OR 7.20, CI 4.73-11.1). In the pTBI group, men (OR 1.26, CI 1.18-1.34) and women (OR 2.05, CI 1.27-3.36) were more likely to interrupt military service than the reference group. The PTBI group scored 0.15 points (CI 0.10-0.20) less than the reference group in cognitive b-test. CONCLUSIONS: PTBI groups had slightly shorter military service periods and higher interruption rate than our reference-group. There were only minor differences between groups in cognitive b-test.

Pediatric traumatic brain injury and early age multiple sclerosis in Finland: A nationwide register-based cohort study.

OBJECTIVE: Examine the link between pediatric traumatic brain injury (pTBI) and early-onset multiple sclerosis in Finland. METHODS: Conducted nationwide register study (1998-2018) with 28,750 pTBI patients (< 18) and 38,399 pediatric references with extremity fractures. Multiple sclerosis diagnoses from Finnish Social Insurance Institution. Employed Kaplan-Meier and multivariable Cox regression for probability assessment, results presented with 95% CI. RESULTS: Of 66 post-traumatic multiple sclerosis cases, 30 (0.10%) had pTBI, and 36 (0.09%) were in the reference group. Cumulative incidence rates (CIR) in the first 10 years were 46.5 per 100,000 (pTBI) and 33.1 per 100,000 (reference). Hazard ratio (HR) for pTBI was 1.10 (95% CI: 0.56-1.48).Stratified by gender, women's CIR was 197.9 per 100,000 (pTBI) and 167.0 per 100,000 (reference) after 15 years. For men, CIR was 44.6 per 100,000 (pTBI) and 34.7 per 100,000 (reference). In the initial 3 years, HR for female pTBI was 1.75 (95% CI: 0.05-6.32), and between years 3 and 20, it was 1.08 (95% CI: 0.51-1.67). For male patients, HR was 1.74 (95% CI: 0.69-4.39). SIGNIFICANCE: We did not find evidence of an association between pTBI and early-onset multiple sclerosis 20 years post-initial trauma.

Health and health behaviours in adolescence as predictors of education and socioeconomic status in adulthood - a longitudinal study.

BACKGROUND: The positive association of health with education level and socioeconomic status (SES) is well-established. Two theoretical frameworks have been delineated to understand main mechanisms leading to socioeconomic health inequalities: social causation and health selection but how these work in adolescence is poorly known. We studied if adolescent health and health behaviours predict higher education and higher SES in adulthood and if family background and school performance in adolescence explain these associations. METHODS: Surveys on health and health behaviours were sent to representative samples of 12-18-year-old Finns in 1981-1997 every second year (response rate 77.8%, N = 55,682). The survey data were linked with the respondents' and their parents' socioeconomic data from the Finnish national registries. Both latent variables, namely, health (perceived health, health complaints, chronic disease), health-compromising behaviours (smoking status, drunkenness frequency), and family background (parents' occupation-based SES, education, family type) and variables directly measuring health-enhancing behaviours (toothbrushing, physical activity) and school performance were used to predict higher education and higher occupation-based SES at age 34. Logistic regression analysis and structural equation models (SEM) were used. RESULTS: In logistic regression analyses, good health, health-enhancing behaviours, and lack of health-compromising behaviours were related to higher education and SES, also after controlling for family background and school performance. In the SEM analyses, good health, health-enhancing behaviours, and lack of health-compromising behaviours directly predicted higher SES and higher education, although the standardised coefficients were low (from 0.034 to 0.12). In all models, health, lack of health-compromising behaviours, and health-enhancing behaviours predicted school performance, which in turn, predicted the outcomes, suggesting indirect routes to these. Good socioeconomic prospects in terms of family background predicted good health, healthy behaviours, and good school performance in adolescence and higher SES and higher education in adulthood. CONCLUSION: Health and health behaviours in adolescence predicted education and SES in adulthood. Even though the relationships were modest, they support the health selection hypotheses and emphasise the importance of adolescence for health inequalities during the life-course. Health and health behaviours were strongly associated with school performance and family background which together modified the paths from health and health behaviours to the outcomes.

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.ClinicalTrials.gov identifier: NCT02953067 24 October 2016.

The association between interpregnancy interval and gestational diabetes mellitus: A nationwide register-based study in Finland.

OBJECTIVE: Previous results on the association between interpregnancy interval (IPI) and gestational diabetes mellitus (GDM) have been contradictory. Hence, the aim of this study was to examine the association between IPI and GDM using high-quality nationwide register data. METHODS: All women with first and second pregnancies during our study period from the National Medical Birth Register during 2004-2018 were considered. A logistic regression model was used to assess the association between the length of the IPI and development of the GDM in the second pregnancy. Women were divided into three groups based on the length of the IPI: short IPI (0-11 months), normal IPI (12-47 months), and long IPI (48+ months). Adjusted odds ratios (aOR) with 95% CI were compared between the groups. RESULTS: A total of 47 078 women were included in the study. We found no evidence of difference when women with short IPI were compared with women with normal IPI (aOR 0.99, 95% CI 0.93-1.05). Women with long IPI had increased odds for the development of GDM when compared with women with normal IPI (aOR 1.28, 95% CI 1.19-1.38). In the logistic regression model for continuous IPI, the total odds for the development of GDM increased as the IPI increased (aOR 1.05 per year, 95% CI 1.03-1.06). CONCLUSION: The odds for the development of GDM increased as the IPI increased. This study's results serve as a clarion call for proactive measures in GDM prevention. Moreover, they advocate for intensified investigation into the underlying factors contributing to GDM among women with extended IPI. It is imperative that these insights inform both clinical practice and further research agendas, as we strive to safeguard maternal health and well-being.

Effect of major trauma on the expected number of births in Finnish women: A nationwide population-based public data and register analysis.

BACKGROUND: The effect of major trauma on subsequent fertility is poorly described. If women have lower fertility after trauma, they would have a lower risk of anti-D mediated hemolytic disease of the fetus and newborn in a future pregnancy following the transfusion of RhD-positive blood to RhD-negative women during their resuscitation. STUDY DESIGN AND METHODS: Data was obtained from the Care Register for Health Care, National Medical Birth Register, and open access data from Statistic Finland to evaluate the effect of major trauma (traumatic brain injuries, spine, pelvic, hip/thigh fractures) on the age-specific number of births during years 1998-2018. The total number of births before a specific maternal age for different trauma populations was calculated and these were compared to the corresponding number of births in the general population. RESULTS: There were 50,923 injured women in this study. All injured women, including when analyzed by the nature of their injury, demonstrated lower expected numbers of births starting at approximately 28 years of age compared to the general population of women in Finland. At age 49, the expected number of births in the general population was approximately 1.8, whereas for all injured women 0.6, women with TBIs and spine fractures 0.6, women with pelvic fractures 0.5, and women with hip or thigh fractures 0.3. DISCUSSION: Injured women are predicted to have lower fertility rates compared to the general population of Finnish women. The lower fertility rate should be considered when planning a blood product resuscitation strategy for injured women.

The incidence, trends, and costs of treatment of femoral shaft fractures among Finnish children aged 2-12 years between 1998 and 2016.

Purpose: The purpose of this study was to determine the incidence and trends of both hip spica casting and elastic stable intramedullary nailing in children aged 2-12 years who sustained femoral diaphyseal fracture between 1998 and 2016 in Finland. We also evaluated the actual hospital costs of both treatment methods as well as calculating the length of hospital stay. Methods: This study included all 2- to 12-year-old children with femoral diaphyseal fracture who were treated in Finland between 1998 and 2016. Data were collected from the National Hospital Discharge Register of Finland. Children were classified by age into five groups. The annual incidences per 100,000 persons were calculated using annual mid-year population census data obtained from Statistics Finland. Data on the annual actual daily hospital costs were collected from the Finnish Institute for Health and Welfare. Results: In total, 1064 patients aged 2-12 years who had sustained femoral diaphyseal fracture were treated with elastic stable intramedullary nailing or hip spica casting between 1998 and 2016. In children aged 4-5 years, the incidence of elastic stable intramedullary nailing increased during the study period from 5.4 per 100,000 persons in 1998 to 8.1 per 100,000 persons in 2016. Conclusions: The length of hospitalization in patients treated with elastic stable intramedullary nailing was shorter and, therefore, the total costs of hospital treatment were lower than in those children treated with hip spica cast. Level of evidence: level III.

Fear of childbirth prolongs interpregnancy interval: A nationwide register-based quantile logistic regression analysis.

Introduction: It is not well studied how fear of childbirth (FOC) influences the interpregnancy interval (IPI). Thus, we aimed to analyze the association between FOC and the length of the IPI. Methods: All women having their first and second pregnancies during the study period (2004-2018) were gathered from the Finnish Medical Birth Register. A logistic regression model was used to assess the association between the FOC and subsequent length of the IPI. The length of the IPI was assessed separately for women with FOC in the first pregnancy, and for women who developed the FOC in the second pregnancy. IPIs with a length in the lower quartal were considered short IPIs, and length in the upper quartal as long IPIs. Adjusted odds ratios (aOR) with 95% CIs were compared between the groups. Results: A total of 52 709 women with short IPI (<1.05 years), 105 604 women with normal IPI, and 52 889 women with long IPI (>2.57 years) were included. A total of 3606 women had FOC in the first pregnancy, and a total of 11 473 had their first FOC diagnosis in the second pregnancy. Women with FOC in the first pregnancy had lower odds for short IPI (aOR 0.88, CI 0.81-0.95) and higher odds for long IPI (aOR 1.30, CI 1.21-1.40). Women with the first FOC diagnosis in the second pregnancy had higher odds for long IPI (aOR 1.68, CI 1.61-1.75), When only vaginal deliveries in the first pregnancy were included, women with FOC in the second pregnancy had lower odds for long IPI (aOR 0.71, CI 0.66-0.75) and higher odds for long IPI (aOR 1.52, CI 1.41-1.62), when only cesarean section was included. Conclusion: The main finding of this study was that women with FOC had notably higher odds for long IPI. The etiologic and background factors behind FOC should be better recognized and prevented, and FOC should not only be considered as a complicating factor for pregnancy and delivery but also a factor that strongly affects the desire of women to get pregnant again.

Physiotherapist-supervised exercises versus unsupervised home-based exercises after nonsurgically treated proximal humerus fracture: a multicenter randomized controlled trial.

BACKGROUND: Proximal humerus fracture (PHF) is a common fragility fracture in older adults and can have a substantial impact on upper limb function. Although most patients with PHF can be treated nonsurgically, it is unknown whether older adults benefit from supervised exercise therapy after PHF. Therefore, the objective of this trial was to investigate whether 10 weeks of physiotherapist-supervised exercises once a week were superior to 10 weeks of unsupervised home-based exercises in older adults with a nonsurgically treated displaced 2-part PHF. METHODS: This was designed as an assessor-blinded, prospective, randomized controlled trial and took place in 3 Nordic countries. In total, 72 patients (≥60 years) with nonsurgically treated displaced 2-part PHF were randomized to either physiotherapist-supervised exercises once a week for 10 weeks, combined with daily home-based exercises, or to 10 weeks of daily unsupervised home-based exercises. The primary outcome measure was the Disability of the Arm, Shoulder, and Hand (DASH) with a primary endpoint at 3 months. Secondary outcomes were DASH (at 12 months), Constant-Murley Score, the 15D-instrument, Visual Analog Scale, General Self-Efficacy Scale, and Pain Catastrophizing Scale, with follow-up visits after 3 and 12 months. Non-union and patient death within 3 months were counted as complications. RESULTS: The mean age of the patients in both groups was 72 years. At 3 months follow-up, the mean DASH score in the supervised group was 25.9 (SD 16.0) compared to 22.4 (SD 18.9) in the unsupervised group. The mean between-group difference (3.5, 95% CI -5.0 to 12.5) was not clinically relevant. None of the secondary outcome measures presented any clinically relevant or statistically significant between-group differences at 3 or 12 months follow-up. One patient in the supervised group and 3 in the unsupervised group were diagnosed with non-union. One patient from each group died before 3 months follow-up. CONCLUSIONS: This trial provides no evidence that supervised exercises are superior to unsupervised home-based exercises in improving functional outcome or health-related quality of life in older patients with a nonsurgically treated 2-part PHF. Further, our results suggest that most older adults with a nonsurgically treated 2-part PHF can perform home-based exercises without the supervision of a physiotherapist.

Suprapatellar tibial fracture nailing is associated with lower rate for acute compartment syndrome and the need for fasciotomy compared with the infrapatellar approach.

BACKGROUND: Intramedullary tibial nailing (IMN) is the gold standard for stabilizing tibial shaft fractures. IMN can be performed through an infra- or suprapatellar approach. PURPOSE: The aim of this study is to compare the rate of fasciotomies for acute compartment syndrome between infra- and suprapatellar approaches. METHODS: A total of 614 consecutive patients who were treated with IMN for tibial fracture between October 2007 and February 2020 were included in the study. The approach used for IMN was determined by the operating surgeon. Infrapatellar IMN was performed with the knee in deep flexion position, with or without calcaneal traction. Suprapatellar IMN was performed in straight or semiflexed position. The diagnosis of compartment syndrome was based on clinical analysis, but for some patients, a continuous compartment pressure measurement was used. The primary outcome was the rate of peri- and postoperative compartment syndrome treated with fasciotomies. RESULTS: The study sample included 513 patients treated with infrapatellar IMN and 101 patients treated with suprapatellar IMN technique. The mean age of the patients was 44.7 years (infrapatellar technique) and 48.4 years (suprapatellar technique). High energy trauma was seen in 138 (27%) patients treated with infrapatellar technique and in 39 (39%) patients treated with suprapatellar technique. In the suprapatellar group (n = 101), there were no cases of peri- or postoperative compartment syndrome treated with fasciotomies. In the infrapatellar group (n = 513), the need for fasciotomies was stated in 67 patients, 31 patients (6.0%) perioperatively and in 36 patients (7.0%) postoperatively. The rate of fasciotomies (0/101 versus 67/513 cases) differed significantly (p < 0.001). There were no significant differences in the fracture morphology or patient demographics between the study groups. CONCLUSIONS: The suprapatellar technique is recommended over the infrapatellar approach in the treatment of tibial shaft fractures. The rate of peri- and postoperative compartment syndrome and the need for fasciotomies was significantly lower with the suprapatellar technique. The major cause of increased rate of peri- or postoperative acute compartment syndrome with infrapatellar IMN technique is presumably associated with the positioning of the patient during the operation.

Intramedullary Nailing of Intertrochanteric Femoral Fractures in a Level I Trauma Center in Finland: What Complications Can be Expected?

BACKGROUND: Intertrochanteric hip fractures are one of the most common fractures in older people, and the number is estimated to increase. These fractures are often treated with intramedullary nailing; however, various complications have been reported. It is important to identify the potential complications and investigate whether the choice of implant and patient-related factors are associated with the risk of complications to develop better strategies for preventing them. QUESTIONS/PURPOSES: (1) In the treatment of intertrochanteric fractures with intramedullary nailing, what are the risks of major complications and 30-day mortality? (2) Which implant types are associated with greater odds of major complications? (3) Which patient-related factors are associated with increased odds of major complications? METHODS: In this retrospective, comparative study, we reviewed the health records of 2397 patients with a femoral fracture treated at one Level I trauma center between January 2014 and November 2020. Of those, we considered patients who were treated with intramedullary nailing for an intertrochanteric fracture after sustaining a low-energy injury as potentially eligible. Based on this criterion, 53% (1279) were eligible; a further 47% (1118) were excluded because the fixation method was other than intramedullary nailing, the fracture pattern was other than intertrochanteric fracture, or the fracture was caused by a high-energy injury mechanism. Another 4% (97) were excluded because they had incomplete datasets because of follow-up less than 12 months, leaving 49% (1182) for analysis. During the study period, intramedullary nails were generally used to treat nearly all intertrochanteric fractures at our hospital. The risk of complications was then assessed by chart review. Acute myocardial ischemia, cutout, nail breakage, pulmonary embolism, sepsis, stroke, and wound infection were defined as major complications. Cutout, nail breakage, and wound infection were defined as major complications leading to reoperation. To examine the association of implant type and major complications, a logistic regression analysis was performed. Additionally, the risks of major complications leading to reoperation were compared between implants. Finally, a univariable logistic regression analysis was performed to examine the association between patient-related factors and major complications. RESULTS: The overall proportion of patients experiencing complications was 16% (183 of 1182), and the crude percentage of 30-day mortality was 9% (107 of 1182) based on the hospital`s medical records. After controlling for patient-related factors such as disease, age, and smoking, we found that nail type was not associated with odds of major complications leading to reoperation (Gamma3: OR 0.86 [95% CI 0.44 to 1.67]; p = 0.67; Trochanteric Fixation Nail: OR 0.61 [95% CI 0.2 to 1.53]; p = 0.33; Proximal Femoral Nail Antirotation: OR 0.55 [95% CI 0.16 to 1.49]; p = 0.29) compared with the Trochanteric Fixation Nail Advanced. Anticoagulation (OR 1.70 [95% CI 1.11 to 2.59]; p = 0.01), congestive heart failure (OR 1.91 [95% CI 1.13 to 3.11]; p = 0.01), and hypertension (OR 1.67 [95% CI 1.08 to 2.63]; p = 0.02) were associated with a major complication. Liver disease (OR 5.19 [95% CI 0.78 to 20.8]; p = 0.04) was associated with a major complication leading to reoperation. CONCLUSION: This study provides a better understanding of the occurrence of surgical and medical complications after intramedullary nailing of intertrochanteric fractures. The new-generation nail types are comparable options based on the risk of reoperation. Anticoagulation, congestive heart failure, and hypertension were associated with major complications, highlighting the need for careful management and monitoring of these comorbidities during intramedullary nailing procedures.Level of Evidence Level III, therapeutic study.