High dose vitamin D supplementation decreases the risk of deficiency in male conscripts, but has no effect on physical performance-A randomized study.

Purpose: Physical load during military training might increase the need for vitamin D; therefore, supplementation could be beneficial for 25(OH)D serum levels and physical performance. Methods: One hundred and twelve male conscripts were randomized into two vitamin D oil capsule supplementation groups: 55 participants in the 600 IU group and 57 in the 4000 IU group with a follow-up period from July 2021 to May 2022. Physical fitness tests were performed in July, October and May. Hand grip strength tests were performed in July, October and January. Blood serum (25(OH)D), parathyroid hormone PTH), calcium and ionized calcium (i-Ca) values were measured in July, October, January and May. Results: The 600 IU group had a lower (p < 0.001) value of 25(OH)D at all time points compared to the 4000 IU group, except at baseline. None of the subjects in the 600 IU group reached sufficient levels of 75 nmol/L of 25(OH)D in January and May. In May, 60% of participants in the 600 IU group and 30% in the 4000 IU group had 25(OH)D levels under 50 nmol/L. No significant differences in PTH or i-Ca values were found between the study groups at any time point. No significant differences at any time point were found in the physical fitness test or hand grip strength test between the groups. Conclusion: A 10-month vitamin D supplementation with 4000 IU decreased the incidence of vitamin D deficiency (<75 nmol/L) in young, male army conscripts during wintertime, but no differences in physical performance were found compared to 600 IU supplementation. Level of Evidence: Level I, Prospective randomized study.

Complications and secondary operations after non-operative and operative treatment of tibial plateau fractures: a population-based study of 562 patients with mean follow-up of 7 years.

INTRODUCTION: The incidence of tibial plateau fractures (TPF) is 1% of all fractures and increases with age. Whether non-operatively or operatively treated, complications (infection, malalignment, loss of reduction and delayed union or nonunion) and post-traumatic osteoarthritis are not uncommon, and the risk for complications has generally been assumed to rise with age. This study investigated all post-TPF complications and secondary surgery after non-operative and operative treatment. Secondary aims were to determine the incidence and epidemiology of TPF in the population of the Central Finland region. MATERIALS AND METHODS: All patients over age 18 years with a TPF, including incidence, etiology, fracture type, and possible complications and reoperations, sustained during the period 1998-2019 were retrospectively identified from hospital records. RESULTS: The annual mean incidence of TPF was 14.4/100,000, with older women at highest risk. The proportions of non-operative and operatively treated patients who had undergone at least one additional surgical operation were 6% and 26%, respectively. Age and female gender were identified as risk factors for complications and secondary operations. The risk peaked in patients aged 60-65 years, decreasing thereafter. Non-operative treatment showed low risk for both non-union and loss of reduction. CONCLUSIONS: Older women were at the highest risk for TPF and for subsequent complications and secondary operations after TPF. Secondary operations after operatively treated TPF were not uncommon and patients aged 60-65 years were at highest risk. Given the low rates of complications and re-operations, non-operative treatment may be a safe option in cases of all minimally displaced TPF.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) may also have a place outside major trauma centers - A case report from a Finnish rural hospital.

The recent adoption of endovascular and hybrid methods in the management of massive bleeding following trauma to the torso and junctional areas has been a major advance in trauma care. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is one tool to tackle immediate exsanguination in such cases. To take advantage of such methods, rapid femoral artery access is crucial. In rural hospitals a trauma surgeon, vascular surgeon and interventional radiologist may not be in the hospital during on-call hours. Furthermore, gaining femoral arterial access is an infrequent procedure for a trauma surgeon working outside major trauma centers. Therefore, it might be difficult to acquire and maintain the requisite skills. However, a consultant anesthesiologist is a member of the trauma team and always on call in our hospital. An experienced anesthesiologist is a valuable asset in ultrasound guided arterial punctures and in inserting intravascular introducer sheaths, as was the case in our patient. To our knowledge, anesthesiologists do not commonly participate in the actual placement of arterial introducer sheaths for REBOA catheters in trauma teams. We wish to bring to notice this hidden asset when a team that does not routinely include a vascular surgeon or an interventional radiologist is treating a seriously injured trauma patient. We report on a patient who had sustained a shrapnel injury to the groin with massive blood loss. To stop further bleeding and to stabilize hemodynamics, we used REBOA to gain proximal control of the bleeding. As a result, the patient avoided surgical retroperitoneal exposure and a dry surgical field was created. We conclude that REBOA may also have a place in rural hospitals, and that, if necessary, trauma team members may adopt novel roles in the treatment of hemorrhage.

Severe deficiency of vitamin D has no negative effect on physical performance during military training.

BACKGROUND: Decreased physical fitness and inferior physical performance are potentially life-threatening risk factors in a combat situation. To examine the effect of vitamin D on physical performance, a prospective study of young men conscripts in the Estonian Army was designed. The hypothesis of the study was that severe deficiency of vitamin D has a negative effect on physical performance. METHODS: All conscripts (N.=410) entering 10-month military service in July 2015 at the Kuperjanov Battalion were asked to participate. Initially, a total of 98 conscripts volunteered to participate. A prospective longitudinal study with a 10-month follow-up period was performed. The Army Physical Fitness Test (APFT) was performed three times, and hand grip strength, and blood serum values of 25(OH)D, parathyroid hormone (PTH) and calcium (Ca) were measured four times. RESULTS: A significant decrease in the levels of 25(OH)D compared with baseline values were found, with a lowest mean value of 31.9 nmol/L in March 2016 (P<0.001). No significant differences were found in serum Ca levels. In March 2016, PTH was significantly higher in the severe deficiency group (<25 nmol/L of 25(OH)D) (P=0.02). No significant differences were found in terms of the APFT or hand grip strength between conscripts with severe deficiency of 25(OH)D or values >25 nmol/L. The main finding of the present study was that severe 25(OH)D deficiency was common among male conscripts during the winter season but had no negative effect on physical performance in terms of the APFT test and hand grip strength test. CONCLUSIONS: Severe vitamin D deficiency during the winter season is common but has no negative effect on physical performance in young, physically active men in military service.

Seven-month wintertime supplementation of 1200 IU vitamin D has no effect on hand grip strength in young, physically active males: A randomized, controlled study.

Background: There has been a growing interest in the role of vitamin D for the well-being and physical performance of humans under heavy training such as conscripts in military service; however, there is a lack of long-term supplementation studies performed on members of this type of young, physically active, male population. The hypothesis of the study was that vitamin D supplementation during wintertime will decrease the prevalence of critically low vitamin D blood serum levels and increase hand grip strength during the winter season among young male conscripts. Study Design: Longitudinal, triple-blinded, randomized, placebo-controlled trial. Methods: Fifty-three male conscripts from the Estonian Army were randomized into two groups: 27 to an intervention group and 26 to a placebo group. The groups were comparable in terms of their demographics. The intervention group received 1200 IU (30 µg) capsules of vitamin D3, and the control group received placebo oil capsules once per day. The length of the follow-up was 7 months, from October 2016 until April 2017. Blood serum vitamin D (25(OH)D), parathyroid hormone (PTH), calcium (Ca), ionized calcium (Ca-i), testosterone and cortisol values, and hand grip strength were measured four times during the study period. Results: The mean 25(OH)D level decreased significantly in the control group to a critically low level during the study, with the lowest mean value of 22 nmol/l found in March 2017. At that time point, 65% in the control group vs 15% in the intervention group had 25(OH)D values of less than 25 nmol/l (p < 0.001). In the intervention group, the levels of 25(OH)D did not change significantly during the study period. All other blood tests revealed no significant differences at any time point. The corresponding result was found for hand grip strength at all time points. Conclusion: Long-term vitamin D supplementation during wintertime results in fewer conscripts in the Estonian Army with critically low serum vitamin D (25(OH)D) levels during the winter season. However, this did not influence their physical performance in the form of the hand grip strength test.

Risk of total knee replacement after proximal tibia fracture: a register-based study of 7,841 patients.

Background and purpose - Post-traumatic knee osteoarthritis following proximal tibia fracture (PTF) is a common complication that may lead to total knee replacement as secondary treatment (TKRS). We determined the risk of TKRS following PTF, whether treated nonoperatively or operatively, and compared the results with a 38-fold control group without prior PTF. Patients and methods - We identified all patients over 18 years of age in Finland with PTF treated during the period 2009-2018 from the Finnish Hospital Discharge Register (FHDR) and Finnish Arthroplasty Register (FAR). Age, sex, treatment method, follow-up time, and possible TKRS were recorded. Results - 7,701 patients were treated for PTF during the period 2009-2018. Over the 5.1-year (SD 3.1) follow-up, TKRS was performed in 340 (4.3%) patients with a prior PTF after a mean of 2.1 (SD 2.0) years post-fracture. TKRS was needed in 138 (3.7%, HR 1.8) patients in the nonoperatively treated group and in 202 (5.0%, HR 3.2) patients in the operatively treated group. Operative treatment, female sex, and high age were identified as risk factors for TKRS. The incidence of TKRS was highest during the first 2 years after fracture and remained elevated throughout the follow-up. Interpretation - Patients with a prior PTF had a 1.8- to 3.2-fold higher risk of TKRS compared with controls during the first 5 years post-fracture. Risk of TKRS was associated with an operatively treated PTF, female sex, and high age. The patients in the operative group likely sustained more complex fractures, while female sex and age may be explained by more osteoporotic bone quality.

Functional results of total-knee arthroplasty versus medial unicompartmental arthroplasty: two-year results of a randomised, assessor-blinded multicentre trial.

OBJECTIVE: The primary objective of the trial was to assess the clinical effectiveness of medial unicompartmental knee arthroplasty versus total knee arthroplasty in patients with isolated medial osteoarthritis of the knee. DESIGN: Prospective, randomised, 2 years, assessor-blind, multicentre, superiority trial. SETTING: The patients were enrolled between December 2015 and May 2018 from the outpatient clinics of three public high-volume arthroplasty hospitals (Finland). PARTICIPANTS: We recruited 143 patients with symptomatic-isolated medial osteoarthritis of the knee needing an arthroplasty procedure. All the patients were suitable for both unicompartmental and total knee arthroplasties. Population was selected as the end-stage-isolated medial osteoarthritis. INTERVENTIONS: All patients, randomized 1:1, received a medial unicompartmental arthroplasty or a total knee arthroplasty through a similar midline skin incision. Patients were blinded to the type of arthroplasty for the whole 2 years of follow-up. MAIN OUTCOME MEASURES: Primary outcome measure was between-group differences in the Oxford Knee Score (OKS) and secondary outcome Knee injury and Osteoarthritis Score (KOOS) at 2 years postoperatively. The changes within and between the groups were analysed with analysis of variance for repeated measurements. RESULTS: The primary outcome was comparable for medial unicompartmental arthroplasty and total knee arthroplasty at 2 years. The mean difference in the OKS between the groups was 1.6 points (95% CI -0.7 to 3.9). In the KOOS subscales, the mean difference between the groups was 0.1 points (95% CI -4.8 to 5.0) for pain, 7.8 points (95% CI 1.5 to 14.0) for symptoms, 4.3 points (95% CI -0.6 to 9.2) for function in daily living, 4.3 points (95% CI -3.0 to 11.6) for function in sports, and 2.1 points (95% CI -4.8 to 9.1) for knee-related quality of life. CONCLUSIONS: The recovery after unicompartmental knee arthroplasty was faster compared with total knee arthroplasty, but unicompartmental arthroplasty did not provide a better patient-reported outcome at 2 years. TRIAL REGISTRATION NUMBER: NCT02481427.

Validity of five foot and ankle specific electronic patient-reported outcome (ePRO) instruments in patients undergoing elective orthopedic foot or ankle surgery.

BACKGROUND: Patient-reported outcomes (PROs) are widely accepted measures for evaluating outcomes of surgical interventions. As patient-reported information is stored in electronic health records, it is essential that there are valid electronic PRO (ePRO) instruments available for clinicians and researchers. The aim of this study was to evaluate the validity of electronic versions of five widely used foot and ankle specific PRO instruments. METHODS: Altogether 111 consecutive elective foot/ankle surgery patients were invited face-to-face to participate in this study. Patients completed electronic versions of the Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), the modified Lower Extremity Function Scale (LEFS), the Manchester-Oxford Foot Questionnaire (MOXFQ), and the Visual Analogue Scale Foot and Ankle (VAS-FA) on the day of elective foot and/or ankle surgery. Construct validity, coverage, and targeting of the scales were assessed. RESULTS: Based on general and predefined thresholds, construct validity, coverage, and targeting of the ePRO versions of the FAAM, the FAOS, the MOXFQ, and the VAS-FA were acceptable. Major issues arose with score distribution and convergent validity of the modified LEFS instrument. CONCLUSIONS: The ePRO versions of the FAAM, the FAOS, the MOXFQ, and the VAS-FA provide valid scores for foot and ankle patients. However, our findings do not support the use of the modified LEFS as an electronic outcome measure for patients with orthopedic foot and/or ankle pathologies.

Structural validity of the Finnish Manchester-Oxford Foot Questionnaire (MOXFQ) using the Rasch model.

BACKGROUND: The 16-item patient-reported Manchester-Oxford Foot Questionnaire (MOXFQ) with subscales of pain, social interactions, and walking/standing has been claimed for strongest scientific evidence in measuring foot and ankle complaints. This study tests the validity of the Finnish MOXFQ for orthopaedic foot and ankle population using the Rasch analysis. METHODS: We translated the MOXFQ into Finnish and used that translation in our study. MOXFQ scores were obtained from 183 patients. Response category distribution, item fit, coverage, targeting, item dependency, ability to measure latent trait (unidimensionality), internal consistency (Cronbach's alpha), and person separation index (PSI) were analyzed. RESULTS: Fifteen of the items had ordered response categories and/or sufficient fit statistics. The subscales provided coverage and targeting. Some residual correlation was noted. Removing one item in the pain subscale led to a unidimensional structure. Alphas and PSIs ranged between 0.68-0.90 and 0.67-0.92, respectively. CONCLUSIONS: Despite some infractions of the Rasch model, the instrument functioned well. The subscales of the MOXFQ are meaningful for assessing patient-reported complaints and outcomes in orthopaedic foot and ankle population.

Minimal important change for the visual analogue scale foot and ankle (VAS-FA).

BACKGROUND: Visual analogue scale foot and ankle (VAS-FA) is a patient-reported outcome measure for foot and ankle disorders. The VAS-FA is validated into several languages and well adopted into use. Nonetheless, minimal important change (MIC) for the VAS-FA has not been estimated thus far. METHODS: The VAS-FA score was obtained from 106 patients undergoing surgery for various foot and ankle complaints. MIC was estimated using an anchor-based predictive method. RESULTS: The adjusted MIC was 6.8 for total VAS-FA score, and 9.3 for the Pain, 5.8 for the Function, and 5.7 for the Other complaints subscales. The VAS-FA score was found to separate improvement and deterioration in patients' foot and ankle condition. CONCLUSIONS: MIC was successfully defined for the VAS-FA in the current study. The VAS-FA can be used to evaluate foot and ankle patients' clinical foot and ankle status and its change. Further research on estimating disease-specific MICs is recommended.

Self-Reported Knee Pain Does Not Impact Physical Training Negatively in Conscripts.

INTRODUCTION: Despite the great number of investigations on the effects of injuries during military service, there is limited information available on the use of self-reported instruments. This study evaluated self-reported knee pain (KP) and its effect on physical performance during military service in the Estonian Defense Forces. MATERIAL AND METHODS: Ninety-five male conscripts aged 19-25 years were divided into two study groups based on the occurrence of KP or not. Self-reported KP and function according to the Knee Injury and Osteoarthritis Outcome Score (KOOS) were measured. Physical fitness level was scored using the Army Physical Fitness Test (APFT). KOOS and APFT were measured in the beginning and at the end of the 6-month period of military service. RESULTS: Significant differences in favor of the group without KP (P < 0.001) were found for all subgroups of the KOOS. In spite of KP, the physical condition improved significantly (P < 0.001) in both study groups as measured with both the APFT test (22.2% increase) and running time (10.3% decrease). CONCLUSION: In conclusion, self-reported KP and limited function according to KOOS did not hinder the improvement of physical condition and running speed as assessed by APFT in Estonian conscripts.

Knee joint replacement as primary treatment for proximal tibial fractures: analysis of clinical results of twenty-two patients with mean follow-up of nineteen months.

PURPOSE: Proximal tibial fractures are typically treated with osteosynthesis. In older patients, this method has been reported to be associated with a high complication rate, risk of post-traumatic osteoarthritis, and long partial or non-weight bearing during the recovery phase. To avoid these problems, primary total knee replacement (TKR) has become an increasingly common treatment option. METHODS: Twenty-two patients (mean age 74 years, SD 12) underwent primary TKR due to tibial plateau fracture. Follow-up data were available for a mean of 19 (SD 16) months. Trauma mechanism, fracture classification, type of prosthesis used, complications, and re-operations during the follow-up were recorded. The Knee Society Score (KSS), Oxford Knee Score (OKS), range of flexion, and patient satisfaction were evaluated. RESULTS: 13/22 of the fractures were due to a low-energy trauma. At final follow-up, mean KSS was 160 (SD 39) and mean OKS 27 (SD 11) points. Mean flexion was 109° (SD 16°). 14/17 of the patients were satisfied or highly satisfied with their post-operative knee and 11/17 reported their knee to be same or better than pre-trauma. 2/22 of the patients had complications requiring revision surgery. CONCLUSION: TKR as a primary definitive method seems to be a useful alternative to osteosynthesis, enabling immediate full weight bearing and rapid mobilization of patients. The risk of complications associated with primary TKR is higher than those reported after TKR due to primary osteoarthritis but lower than those reported after TKR due to secondary osteoarthritis.

Bone tissue content of TGF-beta2 changes with time in human heterotopic ossification after total hip arthroplasty.

Transforming growth factor beta isoforms (TGF-beta(1), TGF-beta(2), and TGF-beta(3)) most likely play a role in bone physiology, but little is known about their relative importance in normal as well as in heterotopic bone. This study focused on possible differences in the localization and relative content of different TGF beta isoforms in heterotopic ossifications (HO) by comparing HOs, which have developed less than 17 months (immature HOs) with those developed 3-9 years (mature HOs). The HOs were harvested after total hip arthroplasty (THA) during revision surgery. The HO samples were decalcified, embedded in paraffin and sectioned. Azan staining was used to evaluate histological structure of the ossifications and immunohistochemical analysis was performed to estimate the localization of three TGF beta isoforms in the HOs. Comparison of different TGF beta isoforms in the immature and the mature ossifications showed that the content of TGF-beta(2) was decreased by almost three times in the mature HO as compared to the immature HO (p = 0.0064). The proportions of other isoforms in HOs did not differ significantly. This study shows that the relative importance of TGF betas change with HO development.