Clinical outcome following magnetic resonance imaging as first-line imaging in low-impact pediatric spine trauma: a single-center retrospective observational study.

BACKGROUND: Pediatric spinal trauma is rare, but the consequences of a missed injury can be devastating. Medical imaging is often needed in addition to physical examination. Conventional radiographs are widely recommended, but their negative predictive value is limited. Computed tomography (CT) is more sensitive but has a higher radiation dose. Magnetic resonance imaging (MRI) has superior soft tissue contrast and lacks ionizing radiation, but it is more expensive and time-consuming. Thus, the debate regarding the most suitable imaging method is still ongoing. OBJECTIVE: This study examined the ability of MRI to exclude injuries requiring surgical treatment as a first-line imaging method in low-impact pediatric spine trauma. MATERIALS AND METHODS: We retrospectively reviewed the medical records and imaging data of children (under 18 years old) who had suspected spinal trauma and were scanned using MRI in our emergency radiology department over a period of 8 years. We assessed the ability of MRI to detect unstable injuries by searching for later occurrences of primarily missed injuries requiring surgery. RESULTS: Of 396 patients (median age 12 years, range 0-17), 114 (29%) had MRI findings suggesting an acute injury. Bony injuries were detected in 78 patients (20%) and ligamentous or other soft tissue injuries in 82 patients (21%). In the subgroup of 376 patients (median age 12 years, range 0-17) with at least 6 months of clinical follow-up, no missed injuries demanding surgical intervention or immobilization occurred after spinal MRI as  first-line imaging. No adverse events related to MRI or anesthesia occurred. CONCLUSION: MRI can detect injuries requiring surgical treatment as a first-line imaging method in suspected low-impact pediatric spinal trauma and is safe to use in this selected population.

Diagnostic yield of emergency MRI in non-traumatic headache.

PURPOSE: Non-traumatic headache is one of the most common neurological complaints in emergency departments. A relatively low diagnostic yield of magnetic resonance imaging (MRI) among outpatients has been previously reported, but studies of emergency patients are lacking. We sought to determine the diagnostic yield of emergency MRI among outpatients presenting to the emergency department with non-traumatic headache. METHODS: In this retrospective cohort study, we analyzed emergency MRI referrals in a tertiary hospital for non-traumatic headache over a five-year period. We recorded patient characteristics, relevant clinical information from the referrals, and imaging outcomes. RESULTS: In total, 696 emergency patients with non-traumatic headache underwent MRI, most within 24 h of presentation. Significant findings related to headache were found in 136 (20%) patients, and incidental findings in 22% of patients. In a multivariate model, the predisposing factors of the significant findings were age, smoking, nausea, and signs/symptoms of infection. The protective factors were numbness and history of migraine. A predictive clinical score reached only moderate performance. CONCLUSION: Although emergency MRI shows headache-related findings in one in five patients, accurate prediction modeling remains a challenge, even with statistically significant predictors and a large sample size.

MRI of odontogenic maxillofacial infections: diagnostic accuracy and reliability.

OBJECTIVES: To determine the diagnostic accuracy of emergency magnetic resonance imaging (MRI) in odontogenic maxillofacial infections, the clinical and surgical significance of MRI findings, and whether MRI can identify the tooth responsible for the infection. METHODS: A retrospective cohort study reviewed 106 emergency neck MRI scans of patients with neck infections of odontogenic origin. The diagnostic accuracy of MRI in identifying abscesses was studied relative to surgical findings. Correlations were analyzed between various MRI findings and clinical results and outcomes, such as the surgical approach (intraoral vs. extraoral). The ability of MRI findings to predict the causative tooth was assessed in a blinded multi-reader setting. RESULTS: Of the 106 patients with odontogenic infections, 77 (73%) had one or more abscesses. Imaging showed a sensitivity, specificity, and accuracy of 0.95, 0.84, and 0.92, respectively, for MRI diagnosis of an odontogenic abscess. Among the imaging findings, mediastinal edema was the strongest predictor of extraoral surgery. MRI showed bone marrow edema in the majority of patients, and multi-reader assessment showed good reliability. MRI was also able to predict the causative tooth accurately. CONCLUSIONS: Emergency neck MRI can accurately detect odontogenic abscesses and reliably point to the causative tooth. These results can increase the utility and reliance on emergency MRI in clinical decision-making.

Magnetic resonance imaging findings in pediatric neck infections-a comparison with adult patients.

BACKGROUND: Differences in the functioning of the immune system and the anatomical proportions of the neck between children and adults lead to different manifestations of deep neck infections. Magnetic resonance imaging (MRI) may serve as an alternative to computed tomography (CT) as the primary imaging modality. OBJECTIVE: To study characteristic MRI findings and the diagnostic accuracy of MRI in pediatric deep neck infections. MATERIALS AND METHODS: We retrospectively studied a cohort of pediatric patients who underwent a neck 3-tesla MRI study over a five-year period. Inclusion criteria were: 1) emergency MRI findings indicating an infection, 2) infection as the final clinical diagnosis, 3) diagnostic image quality verified by the radiologist reading the study and 4) age under 18 years. Patient record data, including surgery reports, were compared with the MRI findings. RESULTS: Data of 45 children were included and analysed. Compared to adults, children had a higher incidence of retropharyngeal infection and lymphadenitis, and a lower incidence of peritonsillar/parapharyngeal infection. MRI showed evidence of an abscess in 34 children. Of these 34 patients, 24 underwent surgery, which confirmed an abscess in 21 but no abscess in three patients. In addition, three patients underwent surgery without MRI evidence of abscess, and an abscess was found in one of these cases. The measures of diagnostic accuracy among the children were sensitivity 0.96, specificity 0.77, positive predictive value 0.89, negative predictive value 0.91 and accuracy 0.89. Compared with adults, children had lower C-reactive protein, but a similar proportion of them had an abscess, and abscess size and rate of surgery were similar. CONCLUSION: Despite the differences in the infection foci, emergency MRI in children had equal diagnostic accuracy to that in adults.

Volumetric Bone Mineral Density in Cementless Total Hip Arthroplasty in Postmenopausal Women: Effects on Primary Femoral Stem Stability and Clinical Recovery.

BACKGROUND: In cementless total hip arthroplasty, femoral stems should preferably not migrate at all postoperatively. This goal is difficult to achieve in postmenopausal women with impaired bone quality. Here, we explored the clinical importance of initial stem migration, measured by radiostereometric analysis (RSA), in women who underwent quantitative computed tomography (CT) of the involved hip preoperatively. METHODS: A prospective cohort of 65 postmenopausal women (mean age, 69 years) with hip osteoarthritis and Dorr type-A or B femoral anatomy underwent total hip arthroplasty with implantation of a tapered, single-wedge femoral stem. Volumetric bone mineral density (BMD) was measured using quantitative CT. Femoral stem translation and rotation were measured using model-based RSA within 3 days after the surgical procedure and were repeated at 3, 5, and 11 months. Postoperative recovery parameters included walking speed, walking activity, and patient-reported outcome measures. Subjects were categorized into 2 groups according to the magnitude of initial 5-month stem subsidence (<2 mm or ≥2 mm); RSA outliers (n = 7) were analyzed separately. RESULTS: Subjects with stem subsidence of ≥2 mm (mean, 3.09 mm [95% confidence interval (CI), 2.70 to 3.47 mm]) had lower intertrochanteric volumetric BMD (p = 0.008). Subjects with subsidence of <2 mm (mean, 0.80 mm [95% CI, 0.51 to 1.09 mm]) had faster improvement of patient-reported outcome measures and exhibited faster walking speed (p = 0.007) and greater walking activity (p = 0.010) at 11 months as well as better Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores (p = 0.002) and RAND 36-Item Health Survey mental component scores (p = 0.006) at 2 years. All cohort stems were osseointegrated at 2 years. CONCLUSIONS: Femoral stem stability and resistance to subsidence were sensitive to adequate intertrochanteric volumetric BMD. Low intertrochanteric volumetric BMD was associated with greater stem migration. With initial migration, clinical recovery was slower and patient-reported outcome measures were less satisfactory. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Operative versus conservative treatment of small, nontraumatic supraspinatus tears in patients older than 55 years: over 5-year follow-up of a randomized controlled trial.

BACKGROUND: Nontraumatic rotator cuff tear is a common shoulder problem that can be treated either conservatively or operatively. In the previous publications of the 1- and 2-year results of this trial, we found no significant between-group clinical differences. The aim of this study was to investigate the differences in mid-term clinical and radiologic outcomes in patients older than 55 years. MATERIALS AND METHODS: One hundred eighty shoulders with symptomatic, nontraumatic supraspinatus tears were randomly assigned to 1 of the 3 cumulatively designed treatment groups: physiotherapy (group 1); acromioplasty and physiotherapy (group 2); and rotator cuff repair, acromioplasty, and physiotherapy (group 3). The change in the Constant score was the primary outcome measure. The secondary outcome measures were the change in the visual analog scale score for pain and patient satisfaction. Radiologic analysis included evaluation of glenohumeral osteoarthritis (OA) and rotator cuff tear arthropathy (CTA). RESULTS: A total of 150 shoulders (mean age, 71 years) were available for analysis after a mean follow-up period of 6.2 years. The mean sagittal tear size of the supraspinatus tendon tear at baseline was 10 mm in all groups (P = .33). During follow-up, 8 shoulders in group 1 and 2 shoulders in group 2 crossed over to rotator cuff repair. The mean baseline Constant score was 57.1, 58.2, and 58.7 in groups 1, 2, and 3, respectively (P = .85). There were no significant differences (P = .84) in the mean change in the Constant score: 18.5 in group 1, 17.9 in group 2, and 20.0 in group 3. There were no statistically significant differences in the change in the visual analog scale pain score (P = .74) and patient satisfaction (P = .83). At follow-up, there were no statistically significant differences in the mean progression of glenohumeral OA (P = .538) or CTA (P = .485) among the groups. However, the mean progression of glenohumeral OA from baseline to follow-up was statistically significant in the trial population (P = .0045). CONCLUSIONS: On the basis of this study, operative treatment is no better than conservative treatment regarding small, nontraumatic, single-tendon supraspinatus tears in patients older than 55 years. Operative treatment does not protect against degeneration of the glenohumeral joint or CTA. Conservative treatment is a reasonable option for the primary initial treatment of these tears.

Overstay and Readmission in Ear, Nose, and Throat Day Surgery-Factors Affecting Postanesthesia Course.

AIMS: Many procedures in ear, nose, and throat (ENT) day surgery are carried out under local anesthesia in Finland, whereas many other countries use general anesthesia. We investigated overstay and readmission rates in local and general anesthesia at Helsinki University Hospital. MATERIAL AND METHODS: We conducted a retrospective study on ENT (n = 1011) day surgery patients within a 3-month period using the hospital's surgery database to collect data pertaining to anesthesia, overstays, readmissions, and contacts within 30 days of surgery. OBJECTIVES: We examined the effect of American Society of Anesthesiologists (ASA) class, age, sex, type of procedure, and anesthesia type on overstay, contact, and readmission rates. RESULTS: A multivariable logistic regression model included ASA class, age, sex, type of procedure, and anesthesia (local vs general). Sex, age, and type of procedure had an effect on the outcomes of overstay, readmission, or contact. With general anesthesia, 3.2% (n = 23) had an overstay or readmission compared to 1.4% (n = 4) after local anesthesia. This was mainly explained by the number of study outcomes in tonsillar surgery that was performed only in general anesthesia. CONCLUSIONS: Day surgery could be done safely using local anesthesia, as the number of study outcomes was no greater than in general anesthesia. Sex, type of procedure, and age affected the rate of study outcomes, but ASA class and anesthesia form did not. Our overstay, contact, and readmission rates are on the same level, or lower, than in international studies.

The Characteristics of Postoperative Mediastinitis During the Changing Phases of Cardiac Surgery.

BACKGROUND: Mediastinitis is a serious complication of open heart surgery associated with high mortality, considerable health care costs, and prolonged hospital stay. We examined characteristics and incidence of mediastinitis during 29 years when indications and patient material have been in a process of change. METHODS: This was a retrospective population-based study comprising all mediastinitis patients more than 16 years of age after open heart surgery between 1990 and 2018 from a population of 1.7 million. Patient records of 50 mediastinitis patients from 2004 to 2014 were reviewed and compared with 120 patients from 1990 to 1999. RESULTS: Annual mediastinitis rate varied 0% to 1.5% with a decreasing trend-from a level exceeding 1.2% to approximately 0.3%-over the study period. In 2004 to 2014 patients with mediastinitis were older, more often smokers, and more often had diabetes mellitus and renal insufficiency than in 1990 to 1999. No difference in length of hospital treatment, antibiotic prophylaxis or treatment, intensive care unit treatment, or mortality was observed between 1990 to 1999 and 2004 to 2014. Coronary artery bypass graft surgery became less common and valve replacement and hybrid operations more common among operations leading to mediastinitis. Staphylococcus aureus increased (from 25% to 56%, p = .005) whereas coagulase-negative staphylococci (46% to 23%, P < .001) and gram-negative bacteria (18% to 12%, P = .033) decreased as causative agents. Surgery for mediastinitis remained similar except introduction of vacuum-assisted closure treatment. CONCLUSIONS: The rate of mediastinitis decreased during these 29 years. No difference in 30-day mortality in mediastinitis was seen: 0.9% in 1990 to 1999 and 2% in 2004 to 2014.

Analysis of weekend effect on mortality by medical specialty in Helsinki University Hospital over a 14-year period.

BACKGROUND: The weekend effect, the phenomenon of patients admitted at the weekend having a higher mortality risk, has been widely investigated and documented in both elective and emergency patients. Research on the issue is scarce in Europe, with the exception of the United Kingdom. We examined the situation in Helsinki University Hospital over a 14-year period from a specialty-specific approach. MATERIALS AND METHODS: We collected the data for all patient visits for 2000-2013, selecting patients with in-hospital care in the university hospital and extracting patients that died during their hospital stay or within 30 days of discharge. These patients were categorized according to urgency of care and specialty. RESULTS: A total of 1,542,230 in-patients (853,268 emergency patients) met the study criteria, with 47,122 deaths in-hospital or within 30 days of discharge. Of 12 specialties, we found a statistically significant weekend effect for in-hospital mortality in 7 specialties (emergency admissions) and 4 specialties (elective admissions); for 30-day post-discharge mortality in 1 specialty (emergency admissions) and 2 specialties (elective admissions). Surgery, internal medicine, neurology, and gynecology and obstetrics were most sensitive to the weekend effect. CONCLUSIONS: The study confirms a weekend effect for both elective and emergency admissions in most specialties. Reducing the number of weekend elective procedures may be necessary. More disease-specific research is needed to find the diagnoses most susceptible.

Root causes of extended length of stay and unplanned readmissions after orthopedic surgery and hand surgery: a retrospective observational cohort study.

BACKGROUND: While previous studies have evaluated the effect of some patient characteristics (e.g. gender, American Society of Anesthesiologists (ASA) class and comorbidity) on outcome in orthopedic and hand day surgery, more detailed information on anesthesia related factors has previously been lacking. Our goal was to investigate the perioperative factors that affect overstay, readmission and contact after day surgery in order to find certain patient profiles more prone to problemed outcomes after day surgery. METHODS: We examined orthopedic and hand day surgery at an orthopedic day surgery unit of Helsinki University Hospital. Patient data of all adult orthopedic and hand day surgery patients (n = 542) over a 3-month period (January 1 - March 31, 2015) operated on at the unit were collected retrospectively using the hospital's surgery database. These data comprised anesthesia and patient records with a follow-up period of 30 days post-operation. Patients under the age of 16 and patients not eligible for day surgery were excluded. Patient records were searched for an outcome of overstay, readmission or contact with the emergency room or policlinic. Pearson chi-square test, Fischer's exact test and multivariable logistic regression were used to analyze the effect of various perioperative factors on postoperative outcome. RESULTS: Various patient and anesthesia related factors were examined for their significance in the outcomes of overstay, readmission or contact. Female gender (p = 0.043), total amount of fentanyl (p = 0.00), use of remifentanil (p = 0.036), other pain medication during procedure (p = 0.005) and administration of antiemetic medication (p = 0.048) emerged as statistically significant on outcome after day surgery. CONCLUSIONS: Overstay and readmission in orthopedic and hand day surgery were clearly connected with female patients undergoing general anesthesia and needing larger amounts of intraoperative opioids. By favoring local and regional anesthesia, side effects of general anesthesia, as well as recovery time, will decrease.

Weekend effect on mortality by medical specialty in six secondary hospitals in the Helsinki metropolitan area over a 14-year period.

BACKGROUND: The weekend effect is the phenomenon of a patient's day of admission affecting their risk for mortality. Our study reviews the situation at six secondary hospitals in the greater Helsinki area over a 14-year period by specialty, in order to examine the effect of centralization of services on the weekend effect. METHODS: Of the 28,591,840 patient visits from the years 2000-2013 in our hospital district, we extracted in-patients treated only in secondary hospitals who died during their hospital stay or within 30 days of discharge. We categorized patients based on the type of each admission, namely elective versus emergency, and according to the specialty of their clinical service provider and main diagnosis. RESULTS: A total of 456,676 in-patients (292,399 emergency in-patients) were included in the study, with 17,231 deaths in-hospital or within 30 days of discharge. A statistically significant weekend effect was observed for in-hospital and 30-day post-discharge mortality among emergency patients for 1 of 7 specialties. For elective patients, a statistically significant weekend effect was visible in in-hospital mortality for 4 of 8 specialties and in 30-day post-discharge mortality for 3 of 8 specialties. Surgery, internal medicine, and gynecology and obstetrics were most susceptible to this phenomenon. CONCLUSIONS: A weekend effect was present for the majority of specialties for elective patients, indicating a need for guidelines for these admissions. More disease-specific research is necessary to find the diagnoses, which suffer most from the weekend effect and adjust staffing accordingly.

Effect of Denosumab on Femoral Periprosthetic BMD and Early Femoral Stem Subsidence in Postmenopausal Women Undergoing Cementless Total Hip Arthroplasty.

Antiresorptive denosumab is known to improve the quality and strength of cortical bone in the proximal femurs of osteoporotic women, but its efficacy in preventing periprosthetic bone loss and reducing femoral stem migration has not been studied in women undergoing cementless total hip arthroplasty. We conducted a single-center, randomized, double-blinded, placebo-controlled trial of 65 postmenopausal women with primary hip osteoarthritis and Dorr type A or B proximal femur anatomy. The patients randomly received subcutaneous injections of denosumab 60 mg or placebo once every 6 months for 12 months, starting 1 month before surgery. The primary endpoint was the change in bone mineral density (BMD) of the proximal femur (Gruen zone 7) at week 48, and the secondary endpoint was stem subsidence measured by radiostereometric analysis (RSA) at week 48. Exploratory endpoints included changes in BMDs of the contralateral hip, lumbar spine and distal radius, serum levels of bone turnover markers, walking speed, walking activity, patient-reported outcome measures, and radiographic assessment of stem osseointegration. The participants underwent vertebral-fracture assessment in an extension safety study at 3 years. Denosumab significantly decreased bone loss in the medial femoral neck (zone 7) and increased periprosthetic BMD in the greater trochanteric region (zone 1) and lesser trochanteric region (zone 6). Denosumab did not reduce temporary femoral stem migration. The migration occurred mainly during the settling period (0 to 12 weeks) after implantation of the prosthesis. All of the stems osseointegrated, as evaluated by RSA and radiographs. There were no intergroup differences in functional recovery. Discontinuation of denosumab did not lead to any adverse events. In conclusion, denosumab increased periprosthetic BMD in the clinically relevant regions of the proximal femur, but the treatment response was not associated with any reduction of initial stem migration. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

Good stability of a cementless, anatomically designed femoral stem in aging women: a 9-year RSA study of 32 patients.

Background and purpose - We previously reported a transient, bone mineral density (BMD)-dependent early migration of anatomically designed hydroxyapatite-coated femoral stems with ceramic-ceramic bearing surfaces (ABG-II) in aging osteoarthritic women undergoing cementless total hip arthroplasty. To evaluate the clinical significance of the finding, we performed a follow-up study for repeated radiostereometric analysis (RSA) 9 years after surgery. Patients and methods - Of the 53 female patients examined at 2 years post-surgery in the original study, 32 were able to undergo repeated RSA of femoral stem migration at a median of 9 years (7.8-9.3) after surgery. Standard hip radiographs were obtained, and the subjects completed the Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index outcome questionnaires. Results - Paired comparisons revealed no statistically significant migration of the femoral stems between 2 and 9 years post-surgery. 1 patient exhibited minor but progressive RSA stem migration. All radiographs exhibited uniform stem osseointegration. No stem was revised for mechanical loosening. The clinical outcome scores were similar between 2 and 9 years post-surgery. Interpretation - Despite the BMD-related early migration observed during the first 3 postoperative months, the anatomically designed femoral stems in aging women are osseointegrated, as evaluated by RSA and radiographs, and exhibit good clinical function at 9 years.

Intensity of 18F-FDG PET Uptake in Culture-Negative and Culture-Positive Cases of Chronic Osteomyelitis.

Microbiologic cultures are not infrequently negative in patients with a histopathologic diagnosis of chronic osteomyelitis. Culture-negative cases may represent low-grade infections with a lower metabolic activity than culture-positive cases. 18F-FDG PET could potentially detect such a difference. We determined whether the level of 18F-FDG PET uptake differs in patients with culture-negative and culture-positive osteomyelitis. We reviewed the clinical charts of 40 consecutive patients, who had diagnostic 18F-FDG PET for a suspected bone infection. Twenty-six patients were eligible with a confirmed diagnosis based on microbiologic cultures and/or histopathologic examination. Sixteen of 26 patients had chronic osteomyelitis. Eight of them had positive cultures, seven had negative cultures, and one patient had no cultures of the biopsy specimen. The patients with histologically and/or microbiologically proven osteomyelitis were correctly interpreted as true positive in the routine clinical reading of 18F-FDG PET images. There was no relationship between the level of 18F-FDG PET uptake and the presence of positive or negative bacterial cultures. The result favors the concept that that culture-negative cases of osteomyelitis are false-negative infections due to nonculturable microbes. 18F-FDG PET may help to confirm the presence of metabolically active infection in these patients and guide their appropriate treatment.

Medium to long-term results of 130 Ankle Evolutive System total ankle replacements-Inferior survival due to peri-implant osteolysis.

BACKGROUND: The study reports the medium to long-term results of 130 Ankle Evolutive System total ankle replacements operated at a single-centre. Previously high amount of peri-implant osteolysis was reported from the same material. METHODS: Between 2002 and 2008 one hundred and thirty consecutive ankles replaced with AES ankle prosthesis were followed both radiologically and clinically. RESULTS: The five-year survival was 87.3% (95% confidence interval (CI) 80.0-92.0%), and ten-year survival 74.9% (95% confidence interval (CI) 65.4-82.2%) at a median follow-up time of 96 months (range 2-161; 8 years). Peri-implant osteolysis was found in 91 (70%) ankles, marked in 78 (60%). 44 ankles (34%) have been revised by filling of the cavities, 24 (18%) by fusion, and 6 by further replacement, resulting in the revision rate of 58%. Osteolysis was the main reason for all revisions. The improvement of the Kofoed Score and pain points was significant (all p<0.0001), and the subjective patient satisfaction was good. CONCLUSIONS: Outcome of the current study was seriously affected by osteolysis and is inferior compared to previous reports.

Are periprosthetic osteolytic lesions in ankle worth bone grafting?

BACKGROUND: We retrospectively evaluated the medium-term follow-up of bone grafting due to periprosthetic osteolytic lesions in ankles. METHODS: 34 ankles (32 patients) with total ankle arthroplasty (TAA) underwent re operation. Indications were large periprosthetic osteolytic lesions or continuous growing of the lesions. The osteolytic lesions were imaged by CT before reoperation and once a year after that. The mean CT follow-up after re operation was 3.8 years (range, 2-6.2 years). Patient's clinical outcome was also monitored. RESULTS: Osteolysis continued to progress in 44 bone grafted lesions (68%) in CT follow-up. Pain (p=0.04) and location of the lesion (p=0.03) were associated with progression of osteolysis. In 18 bone grafted osteolytic lesions (28%) the radiological survival remained excellent. 25 out of 34 ankles showed improvement of the function after bone grafting. CONCLUSIONS: There is no established treatment protocol for osteolysis around TAA. Bone grafting is one alternative in the treatment of osteolytic lesions.

Treatment of Nontraumatic Rotator Cuff Tears: A Randomized Controlled Trial with Two Years of Clinical and Imaging Follow-up.

BACKGROUND: The optimal treatment for symptomatic, nontraumatic rotator cuff tear is unknown. The purpose of this trial was to compare the effectiveness of physiotherapy, acromioplasty, and rotator cuff repair for this condition. We hypothesized that rotator cuff repair yields superior results compared with other treatment modalities. METHODS: One hundred and eighty shoulders with symptomatic, nontraumatic, supraspinatus tears were randomized into one of three cumulatively designed intervention groups: the physiotherapy-only group (denoted as Group 1), the acromioplasty and physiotherapy group (denoted as Group 2), and the rotator cuff repair, acromioplasty, and physiotherapy group (denoted as Group 3). The Constant score was the primary outcome measure. Secondary outcome measures were visual analog scale for pain, patient satisfaction, rotator cuff integrity in a control imaging investigation, and cost of treatment. RESULTS: One hundred and sixty-seven shoulders (160 patients) were available for analysis at two years. There were no significant differences (p = 0.38) in the mean change of Constant score: 18.4 points (95% confidence interval, 14.2 to 22.6 points) in Group 1, 20.5 points (95% confidence interval, 16.4 to 24.6 points) in Group 2, and 22.6 points (95% confidence interval, 18.4 to 26.8 points) in Group 3. There were no significant differences in visual analog scale for pain scores (p = 0.45) and patient satisfaction (p = 0.28) between the groups. At two years, the mean sagittal size of the tendon tear was significantly smaller (p < 0.01) in Group 3 (4.2 mm) compared with Groups 1 and 2 (11.0 mm). Rotator cuff repair and acromioplasty were significantly more expensive than physiotherapy only (p < 0.01). CONCLUSIONS: There was no significant difference in clinical outcome between the three interventions at the two-year follow-up. The potential progression of the rotator cuff tear, especially in the non-repaired treatment groups, warrants further follow-up. On the basis of our findings, conservative treatment is a reasonable option for the primary initial treatment for isolated, symptomatic, nontraumatic, supraspinatus tears in older patients. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

[Diagnosis of soft tissue tumors--multidisciplinary collaboration]. / Pehmytkudoskasvainten diagnostiikka--moniammatillista yhteistyötä.

The number of soft tissue sarcomas found in Finland yearly is around 200 cases. Benign soft tissue tumors are common. The patients having a tumor with a deep location in the tissue or a large superficial tumor should be readily referred for imaging studies and consultations with the sarcoma teams of university hospitals. The diagnosis of sarcoma is based on medical history, clinical examination, imaging, examination of a biopsy, and frequently also on molecular genetic analyses. In imaging, the best resolution is provided by MRI. Targeting of the biopsy is an essential part of imaging. Gradus is the most important histology-based factor affecting the prognosis and treatment of the tumor.

Adverse reaction to metal debris after ReCap-M2A-Magnum large-diameter-head metal-on-metal total hip arthroplasty.

BACKGROUND AND PURPOSE: The clinical findings of adverse reaction to metal debris (ARMD) following large-diameter-head metal-on-metal total hip arthroplasty (LDH MoM THA) may include periarticular fluid collections, soft tissue masses, and gluteal muscle necrosis. The ReCap-M2a-Magnum LDH MoM THA was the most commonly used hip device at our institution from 2005 to 2012. We assessed the prevalence of and risk factors for ARMD with this device. METHODS: 74 patients (80 hips) had a ReCap-M2a-Magnum LDH MoM THA during the period August 2005 to December 2006. These patients were studied with hip MRI, serum chromium and cobalt ion measurements, the Oxford hip score questionnaire, and by clinical examination. The prevalence of ARMD was recorded and risk factors for ARMD were assessed using logistic regression models. The mean follow-up time was 6.0 (5.5-6.7) years. RESULTS: A revision operation due to ARMD was needed by 3 of 74 patients (3 of 80 hips). 8 additional patients (8 hips) had definite ARMD, but revision was not performed. 29 patients (32 hips) were considered to have a probable or possible ARMD. Altogether, 43 of 80 hips had a definite, probable, or possible ARMD and 34 patients (37 hips) were considered not to have ARMD. In 46 of 78 hips, MRI revealed a soft tissue mass or a collection of fluid (of any size). The symptoms clicking in the hip, local hip swelling, and a feeling of subluxation were associated with ARMD. INTERPRETATION: ARMD is common after ReCap-M2a-Magnum total hip arthroplasty, and we discourage the use of this device. Asymptomatic patients with a small fluid collection on MRI may not need instant revision surgery but must be followed up closely.

Total ankle arthroplasty: optimizing computed tomography imaging protocol.

OBJECTIVE: To evaluate parameters and positioning when imaging total ankle prostheses on computed tomography (CT). MATERIALS AND METHODS: An ankle prosthesis implanted into a pig's knee joint underwent 16 different CT imaging protocols. Four defects were drilled around prosthesis components simulating periprosthetic osteolytic lesions. The specimen with the implant was imaged in four different orientations with the tibial stem parallel to the table and at 25, 45, and 90° angles to it. The protocol consisted of scanning at 100, 120, and 140 kVp in every position with a pitch of 1.2. The scanning at 120 kVp in every position was repeated with a pitch of 1.0. RESULTS: CT proved to be a reliable imaging modality when studying periprosthetic lesions adjacent to the ankle prosthesis when the tibial stem alignment was parallel to the table. When imaging at higher angles, metal artifacts distorted the image, making the analysis of periprosthetic bone structure unreliable. There were no statistically significant differences between different tube voltages or pitch in volume measurements of the osteolytic lesions. CONCLUSIONS: CT is a reliable imaging method to evaluate periprosthetic bone structure around ankle prostheses when orientation of the prosthesis and acquisition parameters is optimized.