Arthroscopic Bankart versus open Latarjet as a primary operative treatment for traumatic anteroinferior instability in young males: a randomised controlled trial with 2-year follow-up.

OBJECTIVES: To compare the success rates of arthroscopic Bankart and open Latarjet procedure in the treatment of traumatic shoulder instability in young males. DESIGN: Multicentre randomised controlled trial. SETTING: Orthopaedic departments in eight public hospitals in Finland. PARTICIPANTS: 122 young males, mean age 21 years (range 16-25 years) with traumatic shoulder anteroinferior instability were randomised. INTERVENTIONS: Arthroscopic Bankart (group B) or open Latarjet (group L) procedure. MAIN OUTCOME MEASURES: The primary outcome measure was the reported recurrence of instability, that is, dislocation at 2-year follow-up. The secondary outcome measures included clinical apprehension, sports activity level, the Western Ontario Shoulder Instability Index, the pain Visual Analogue Scale, the Oxford Shoulder Instability Score, the Constant Score and the Subjective Shoulder Value scores and the progression of osteoarthritic changes in plain films and MRI. RESULTS: 91 patients were available for analyses at 2-year follow-up (drop-out rate 25%). There were 10 (21%) patients with redislocations in group B and 1 (2%) in group L, p=0.006. One (9%) patient in group B and five (56%) patients in group L returned to their previous top level of competitive sports (p=0.004) at follow-up. There was no statistically significant between group differences in any of the other secondary outcome measures. CONCLUSIONS: Arthroscopic Bankart operation carries a significant risk for short-term postoperative redislocations compared with open Latarjet operation, in the treatment of traumatic anteroinferior instability in young males. Patients should be counselled accordingly before deciding the surgical treatment. TRIAL REGISTRATION NUMBER: NCT01998048.

Syndesmosis fixation in supination-external rotation ankle fractures. Long-Term results of a prospective randomised study.

BACKROUND: The clinical relevance and treatment of syndesmosis injury in supination-external rotation (SER) ankle fractures are controversial. METHODS: After malleolar fixation 24 SER 4 ankle fracture patients with unstable syndesmosis in external rotation stress test were randomised to syndesmosis transfixation with a screw (13 patients) or no fixation (11 patients). Mean follow-up time was 9.7 years (range, 8.9-11.0). The primary outcome measure was the Olerud-Molander Ankle Outcome Score (OMAS). Secondary outcome measures included ankle mortise congruity and degenerative osteoarthritis, 100-mm visual analogue scale for function and pain, RAND 36-Item Health Survey, and range of motion. RESULTS: Mean OMAS in the syndesmosis transfixation group was 87.3 (SD 15.5) and in the no-syndesmosis-fixation group 89.0 (SD 16.0) (difference between means 1.8, 95% CI -10.4-14.0, P = 0.76). There were no differences between the two groups in secondary outcome measures. CONCLUSION: With the numbers available, SER 4 ankle fractures with unstable syndesmosis can be treated with malleolar fixation only, with good to excellent long-term functional outcome.

Non-surgical and surgical treatments for rotator cuff disease: a pragmatic randomised clinical trial with 2-year follow-up after initial rehabilitation.

BACKGROUND: Rotator cuff disease (RCD) causes prolonged shoulder pain and disability in adults. RCD is a continuum ranging from tendinopathy to full-thickness tendon tear. Recent studies have shown that subacromial decompression and non-surgical treatments provide equivalent results in RCD without a full-thickness tendon lesion. However, the importance of surgery for full-thickness tendon tears remains unclear. METHODS: In a pragmatic, randomised, controlled trial, 417 patients with subacromial pain underwent 3-month initial rehabilitation and MRI arthrography (MRA) for the diagnosis of RCD. Of these, 190 shoulders remained symptomatic and were randomised to non-surgical or surgical treatments. The primary outcomes were the mean changes in the Visual Analogue Scale for pain and the Constant Murley Score for shoulder function at the 2-year follow-up. RESULTS: At the 2-year follow-up, both non-surgical and surgical treatments for RCD reduced pain and improved shoulder function. The scores differed between groups by 4 (95% CI -3 to 10, p=0.25) for pain and 3.4 (95% CI -0.4 to 7.1, p=0.077) for function. Among patients with full-thickness ruptures, the reduction in pain (13, 95% CI 5 to 22, p=0.002) and improvement in function (7.0, 95% CI 1.8 to 12.2, p=0.008) favoured surgery. CONCLUSIONS: Non-surgical and surgical treatments for RCD provided equivalent improvements in pain and function. Therefore, we recommend non-surgical treatment as the primary choice for patients with RCD. However, surgery yielded superior improvement in pain and function for full-thickness rotator cuff rupture. Therefore, rotator cuff repair may be suggested after failed non-surgical treatment. TRIAL REGISTRATION DETAILS: ClinicalTrials.gov, NCT00695981 and NCT00637013.

Fibular nailing for fixation of ankle fractures in patients at high risk of surgical wound infection.

BACKGROUND: Postoperative infection is a severe complication after operative treatment of ankle fractures, associated with age, comorbidities, and severe soft tissue injuries. We assessed the efficacy of intramedullary fibular nailing for treating ankle fractures in patients at high risk of wound complications. METHODS: 41 high-risk patients were included in the study. We retrospectively reviewed the medical records to assess the risk profile, the treatment data, and possible infections and re-operations. After a minimum of 2 years eight patients had died, three had advanced-staged dementia and two were lost to follow-up. Remaining 28 patients reported the functional outcome and QoL through patient-reported questionnaires. Radiographs and cone-beam computed tomography were performed, as well as range-of-motion was measured. RESULTS: No surgical wound infections were found. The mean Olerud-Molander score was 67 points (SD 28 [20-100]). The osteoarthritis stages and the range-of-motion were significantly different between the injured and uninjured ankles, but we detected no significant effect on the QoL. CONCLUSION: Intramedullary fibular fixation appeared to be a safe treatment choice for ankle fractures in high-risk patients. LEVEL OF EVIDENCE: IV.

Early palmar plate fixation of distal radius fractures may benefit patients aged 50 years or older: a randomized trial comparing 2 different treatment protocols.

Background and purpose - There is no consensus regarding optimal treatment of displaced distal radius fractures (DRFs). We compared the results of 2 treatment protocols: early palmar plating vs. primary nonoperative treatment of displaced DRFs. Patients and methods - We performed a prospective randomized controlled study including 80 patients aged ≥ 50 years with dorsally displaced DRFs, excluding AO type C3 fractures. Patients were randomized to undergo either immediate surgery with palmar plating (n = 38), or initial nonoperative treatment (n = 42) after successful closed reduction in both groups. Delayed surgery was performed in nonoperatively treated patients showing early loss of alignment (n = 16). The primary outcome measure was Disabilities of the Arm, Shoulder, and Hand (DASH) score. Results - Mean DASH scores at 24 months in the early surgery group were 7.9 vs. 14 in the initial nonoperative group (difference between means 6, 95% CI 0.1-11, p = 0.05). Delayed operation was performed on 16/42 of patients due to secondary displacement in the initial nonoperative group. In "as treated" analysis, DASH scores were 7 in the early surgery group, 13 in the nonoperative group, and 17 after delayed surgery (p = 0.02). The difference in DASH scores between early and delayed surgery was 9 points (CI 0.3-19, p = 0.02) Interpretation - Treatment of DRFs with early palmar plating resulted in better 2-year functional outcomes for ≥50-year-old patients compared with a primary nonoperative treatment protocol. Delayed surgery in case of secondary displacement was not beneficial in terms of function.

Long-term results of arthroscopic Bankart repair: Minimum 10 years of follow-up.

PURPOSE: This study investigated the long-term results of arthroscopic Bankart repair in terms of rates and timelines of recurrence of instability, with special interest in young adult patients aged ≤20 years. METHODS: Between 2000 and 2005, 186 shoulders [182 patients, 50 women, median age 26 (range 15-58) years] were operated on at a university hospital using arthroscopic Bankart repair because of instability after traumatic anteroinferior shoulder dislocation. Medical records were retrospectively reviewed and patients were assessed using postal questionnaires or telephone interview after a minimum of 10 years of follow-up [median 12.2 (range 10-16) years]. The primary outcome measure was recurrence of instability (assessed from 167 shoulders), other outcome measures included Oxford instability score (OIS), subjective shoulder value (SSV), and Western Ontario instability index (WOSI) (assessed from 157 shoulders). RESULTS: At the end of follow-up, 50/167 shoulders (30%) had recurrence of instability and 30/167 (18%) were subjected to reoperation due to instability symptoms. Twenty-six (52%) failures occurred within ≤2 years, 11 (22%) within 2-5 years, and 13 (26%) >5 years after surgery. Failure rate was 19/35 (54%) for patients aged ≤20 years and 31/132 (24%) for patients aged >20 years; reoperation rates were 11/35 (31%) and 19/132 (14%), respectively. Mean OIS was 20 (SD 9, range 12-50), SSV 83% (SD 21, range 10-100), and WOSI score 80 (SD 22, range 33-100). CONCLUSIONS: Nearly one-third of patients had recurrence of instability after arthroscopic Bankart repair after a minimum of 10-year follow-up. Patients aged ≤20 years did poorly with more than half of the patients having recurrence; alternative stabilization techniques should probably be considered for these patients. LEVEL OF EVIDENCE: IV.

The functional outcome and quality of life after treatment of isolated medial malleolar fractures.

BACKGROUND: The optimal treatment of isolated medial malleolar fractures is widely debated. The aim of this study is to analyse the different treatment methods. METHODS: The study included 137 patients with an isolated medial malleolar fracture treated at our hospital between 2000 and 2010. Functional outcome was assessed using Olerud-Molander score and health-related quality-of-life (HRQoL) was measured with RAND36 item health survey. Patients were sent follow-up questionnaires after an average of 9.5 years (4.3-15.2) from the date of treatment. RESULTS: The overall improvement in function was equivalent in both operative and non-operative treatment groups. However, the outcome scores declined in both groups as the primary displacement increased, regardless of the treatment method. HRQoL was similar in both groups. CONCLUSIONS: If maximal fracture displacement is ≤2mm, isolated medial malleolar fractures can be treated non-operatively with good outcome, but the operative treatment may also be performed without serious complications. The degree of fracture displacement is an independent risk factor for inferior functional result, regardless of the treatment method. LEVEL OF EVIDENCE: Therapeutic level of evidence: IV, retrospective cohort study.

Discovery Elbow System: clinical and radiological results after 2- to 10-year follow-up.

BACKGROUND: Discovery Elbow System (DES) is a semi-constrained prosthesis, mainly used for patients with rheumatoid arthritis (RA). METHODS: Records from 79 patients with RA (90 DES arthroplasties) were reviewed; 47 patients with 55 DES elbows were re-examined. Range of motion (ROM) of both elbows, upper limb function, and quality of life (Disabilities of the Arm, Shoulder, and Hand [DASH] score, Mayo Elbow Performance Score [MEPS], and the RAND 36-Item Health Survey [RAND-36]) were assessed. Cementing quality was assessed, and radiolucent lines measured from plain radiographs. Mean follow-up was 64 (range 24-123) months. RESULTS: Pre-operatively to post-operatively, mean elbow flexion improved from 120° to 146° (p < 0.001) and mean extension lag improved from 29° to 24° (p = 0.02), respectively. At follow-up, mean supination was 66°, mean pronation was 69°, and mean grip strength was 14 kg. Grip strength and ROM (except supination) were similar between the DES elbow and contralateral un-operated elbow. Mean post-operative MEPS was 93 points (excellent, n = 38; good, n = 14; fair, n = 2; and poor, n = 1). Mean DASH score was 43 points. The RAND-36 showed that physical functioning, physical role functioning, bodily pain, and general health were lower than the Finnish reference values. Primary cementing was challenging, and radiolucent lines appeared during follow-up. Four prostheses were revised because of aseptic loosening (n = 3) and periprosthetic fracture (n = 1). CONCLUSION: DES provides significant improvement in patient's flexion-extension arc. Cementing of the elbow prosthesis was challenging; radiolucent lines appeared during the 5-year follow-up, but their clinical relevance remains unclear. First-generation locking screws may loosen over time. LEVEL OF EVIDENCE: Level IV.

Treatment of proximal humerus fractures in the elderly: a systemic review of 409 patients.

BACKGROUND AND PURPOSE: There is no consensus on the treatment of proximal humerus fractures in the elderly. PATIENTS AND METHODS: We conducted a systematic search of the medical literature for randomized controlled trials and controlled clinical trials from 1946 to Apr 30, 2014. Predefined PICOS criteria were used to search relevant publications. We included randomized controlled trials involving 2- to 4-part proximal humerus fractures in patients over 60 years of age that compared operative treatment to any operative or nonoperative treatment, with a minimum of 20 patients in each group and a minimum follow-up of 1 year. Outcomes had to be assessed with functional or disability measures, or a quality-of-life score. RESULTS: After 2 independent researchers had read 777 abstracts, 9 publications with 409 patients were accepted for the final analysis. No statistically significant differences were found between nonoperative treatment and operative treatment with a locking plate for any disability, for quality-of-life score, or for pain, in patients with 3- or 4-part fractures. In 4-part fractures, 2 trials found similar shoulder function between hemiarthroplasty and nonoperative treatment. 1 trial found slightly better health-related quality of life (higher EQ-5D scores) at 2-year follow-up after hemiarthroplasty. Complications were common in the operative treatment groups (10-29%). INTERPRETATION: Nonoperative treatment over locking plate systems and tension banding is weakly supported. 2 trials provided weak to moderate evidence that for 4-part fractures, shoulder function is not better with hemiarthroplasty than with nonoperative treatment. 1 of the trials provided limited evidence that health-related quality of life may be better at 2-year follow-up after hemiarthroplasty. There is a high risk of complications after operative treatment.

TightRope versus clavicular hook plate fixation for unstable distal clavicular fractures.

PURPOSE: This retrospective study aimed to compare the fracture union and functional results of clavicular hook plate fixation versus arthroscopy-assisted TightRope fixation of unstable fractures of the distal clavicle. MATERIALS AND METHODS: Forty patients with unstable (Neer II) distal clavicular fracture were treated surgically using either a clavicular hook plate (n=19) or arthroscopy-assisted TightRope fixation (n=21) between 2007 and 2012 in our hospital. Medical records were retrospectively reviewed. Clinical and radiological results after an average period of 62 months for the clavicular hook plate and 32 months for TightRope were assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH) score, the Constant score, and the RAND 36-item health questionnaire. RESULTS: One fracture in each group was failed to unite. The mean Constant score was 93 in the TightRope group and 89 in the clavicular hook plate group, with mean DASH scores of 6 and 11, respectively. According to data from the RAND 36-item questionnaire, health-related quality of life returned to normal in both groups. Removal of the plate was the main reason for reoperation. CONCLUSIONS: TightRope and clavicular hook plate repairs of unstable distal clavicular fractures result in similar fracture union and good clinical outcomes.

Results of parallel plate fixation of comminuted intra-articular distal humeral fractures.

BACKGROUND: This study investigated the results of parallel plate fixation of comminuted distal humeral fractures in a consecutive series of patients. METHODS: Parallel plate fixation was used in 47 patients (30 women), mean age 60 years (range 18-98 years), with Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C distal humeral fractures during 2007 to 2011. Medical records and radiographs were retrospectively assessed. Thirty-five patients completed Disabilities of Arm, Shoulder and Hand (DASH) outcome measure and the RAND Medical Outcomes Study 36-Item Short Form (SF-36) Health Survey. Twenty-seven patients underwent clinical examination, Mayo Elbow Performance Score (MEPS) rating, and radiography after 3.9 years (range, 1.6-7.9 years) of follow-up. RESULTS: The mean flexion arc was lower on the affected side vs the unaffected elbow (123° vs 140°, P = .03). The mean MEPS was 88; the result was excellent in 14, good in 8, fair in 3, and poor in 2 patients. DASH results indicated slight impairment of upper extremity function compared with the reference value (26 vs 10, P = .001). RAND SF-36 scores indicated normal quality of life compared with reference values from the Finnish population. Forty-four fractures united uneventfully. One case each of nonunion and malunion occurred. One olecranon osteotomy failed to unite. There were 3 cases of infection. Prominent hardware was a common late problem, and plates often required removal. The complication rate was 7 of 47 (15%); 4 of these patients (9%) required reoperation. The hardware removal rate was 13 of 47 (28%). CONCLUSION: Parallel plate fixation is an effective method to treat comminuted distal humeral fractures. Good elbow function can be restored in most cases with minor impairments that do not worsen quality of life.

Cost-effectiveness of shoulder arthroplasty for osteoarthritis and rotator cuff tear arthropathy. An economic analysis using real-world data.

INTRODUCTION: This study aimed to assess cost-effectiveness of shoulder arthroplasty for osteoarthritis (OA) and rotator cuff tear arthropathy (CTA) from the perspective of a publicly funded health care system using patient data, health utilities and costs from a real-world situation. HYPOTHESIS: Our hypothesis was that arthroplasty for OA is more cost-effective than for CTA. MATERIAL AND METHODS: We gathered a cohort of patients with 153 anatomic total shoulder arthroplasty (TSA) for OA and 107 reverse shoulder arthroplasty (RSA) for CTA between years 2016-2020 at a university hospital. Short-term (mean 2.8years) shoulder function, health utilities and costs were obtained from prospectively collected data, and a Markov cohort simulation was carried out to assess lifetime cost-utility. The primary outcome measures were change in 15D score to calculate gain in quality-adjusted life years (QALYs) and change in Western Ontario osteoarthritis score of the shoulder (WOOS). RESULTS: Both TSA and RSA restored shoulder function well, WOOS improvement was 59.7 (95% CI: 56.2-63.2) and 55.8 (95% CI: 50.4-61.2), respectively. The cost/QALY gained was 20,846.82 € for TSA and 38,711.90 € for RSA. The cost-utility was not remarkable sensitive to costs, discounting of future costs or estimated revision rates. However, the cost-effectiveness was very sensitive to change in 15D health utility scores and thus QALY gain, especially for RSA patients. DISCUSSION: Shoulder arthroplasty restores shoulder function well in both OA and CTA. In health economic terms, RSA is less cost-effective than TSA in an everyday setting, mainly due to inferior improvement of health-related quality-of-life and reduced life expectancy of CTA patients. LEVEL OF EVIDENCE: III; case series.

Conservative treatment, plate fixation, or prosthesis for proximal humeral fracture. A prospective randomized study.

BACKGROUND: Proximal humerus fracture is the third most common fracture type after hip and distal radius fracture in elderly patients. A comprehensive study by Palvanen et al. demonstrated an increase in the annual fracture rate of 13.7% per year over the past 33 years. Should this trend continue, the fracture rate would triple over the next three decades. The increasing incidence of low-energy fractures raises questions about the optimal treatment in terms of functional outcome, pain, and rehabilitation time, as well as the economical impact. Despite the high incidence and costs of proximal humerus fractures, there is currently no valid scientific evidence for the best treatment method. Several publications, including a Cochrane review outline the need for high-quality, well-designed randomized controlled trials. METHODS/DESIGN: The study is a prospective, randomized, national multi-center trial. The hypothesis of the trial is that surgical treatment of displaced proximal humerus fractures achieves better functional outcome, pain relief, and patient satisfaction compared to conservative treatment. The trial is designed to compare conservative and surgical treatment of proximal humerus fractures in patients 60 years and older. The trial includes two strata. Stratum I compares surgical treatment with locking plates to conservative treatment for two-part fractures. Stratum II compares multi-fragmented fractures, including three- and four-part fractures. The aim of Stratum II is to compare conservative treatment, surgical treatment with the Philos locking plate, and hemiarthroplasty with an Epoca prosthesis. The primary outcome measure will be the Disabilities of the Arm, Shoulder and Hand (DASH) score and the secondary outcome measures will be the EuroQol-5D (EQ-5D) value, OSS, Constant-Murley Score, VAS, and 15D.Recruiting time will be 3 years. The results will be analyzed after the 2-year follow-up period. DISCUSSION: This publication presents a prospective, randomized, national multi-center trial. It gives details of patient flow, randomization, aftercare and also ways of analysis of the material and ways to present and publish the results. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01246167.

Scandinavian Olecranon Research in the Elderly (SCORE): protocol for a non-inferiority, randomised, controlled, multicentre trial comparing operative and conservative treatment of olecranon fractures in the elderly.

INTRODUCTION: The incidence of olecranon fractures is growing in the elderly population. The traditional operative approach is giving way among the elderly to conservative treatment, which seems to provide a comparable functional outcome with a lower complication burden. However, there is still a lack of reliable evidence to support this shift.The objective of this trial is to investigate whether conservative treatment of displaced olecranon fractures in patients aged 75 or older yields comparable results to those of operative treatment in terms of pain and daily function. METHODS AND ANALYSIS: Scandinavian Olecranon Research in the Elderly (SCORE) is a randomised, controlled, multicentre, non-inferiority trial. Eligible patients will be randomised to either conservative or operative treatment. The sample size will be 68 patients and allocation done at a 1:1 ratio (34 patients per group). The randomisation is stratified according to the participating hospital and patient's sex. Both groups will receive the same postoperative physiotherapy and pain management. The primary outcome is Disabilities of the Arm, Shoulder and Hand at 1-year follow-up. Secondary outcomes are pain and satisfaction measured on visual analogue scales, Patient Reported Elbow Evaluation, range of motion of the elbow and extension strength of the elbow compared with the unaffected arm. Radiographs will be taken at each follow-up. Primary analysis of the results will be conducted on an intention-to-treat basis. ETHICS AND DISSEMINATION: The study protocol for this clinical trial has been approved by the Ethics Committee of the Hospital District of Southwest Finland and will be submitted for approval to the Regional Ethics Committees in Linköping, Sweden and Copenhagen, Denmark. Every recruiting centre will apply local research approvals. The results of this study will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04401462. PROTOCOL VERSION: This is the second protocol version dated on 16 April 2020.

Syndesmotic fixation in supination-external rotation ankle fractures: a prospective randomized study.

BACKGROUND: This study was designed to assess whether transfixion of an unstable syndesmosis is necessary in supination-external rotation (Lauge-Hansen SE/Weber B)-type ankle fractures. METHODS: A prospective study of 140 patients with unilateral Lauge-Hansen supination-external rotation type 4 ankle fractures was done. After bony fixation, the 7.5-Nm standardized external rotation (ER) stress test for both ankles was performed under fluoroscopy. A positive stress examination was defined as a difference of more than 2 mm side-to-side in the tibiotalar or tibiofibular clear spaces on mortise radiographs. If the stress test was positive, the patient was randomized to either syndesmotic transfixion with 3.5-mm tricortical screws or no syndesmotic fixation. Clinical outcome was assessed using the Olerud-Molander scoring system, RAND 36-Item Health Survey, and Visual Analogue Scale (VAS) to measure pain and function after a minimum 1-year of followup. RESULTS: Twenty four (17%) of 140 patients had positive standardized 7.5-Nm ER stress tests after malleolar fixation. The stress view was positive three times on tibiotalar clear space, seven on tibiofibular clear space, and 14 times on both tibiotalar and tibiofibular clear spaces. There was no significant difference between the two randomization groups with regards to Olerud-Molander functional score, VAS scale measuring pain and function, or RAND 36-Item Health Survey pain or physical function at 1 year. CONCLUSION: Relevant syndesmotic injuries are rare in supination-external rotation ankle fractures, and syndesmotic transfixion with a screw did not influence the functional outcome or pain after the 1-year followup compared with no fixation.

Stability-Based Classification of Ankle Fractures-The Long-Term Outcome After 11-13 Years of Follow-up.

OBJECTIVES: To assess the long-term functional and radiological outcome, as well as complications and reoperations of ankle fracture patients treated based on stability classification. DESIGN: Retrospective. SETTING: Main Trauma Center, University Hospital. PATIENTS AND INTERVENTIONS: One hundred sixty patients were treated based on stability classification. After a mean follow-up of 12 years, 102 patients were assessed; 67 visited the outpatient clinic, and standard standing ankle radiographs were taken; osteoarthritis (OA) was graded according to Kellgren-Lawrence classification. The remaining patients (n = 35) were followed up via mail or telephone. The complications and reoperations of all 160 patients were collected from electronic patient records. MAIN OUTCOME MEASURES: Olerud-Molander ankle score, foot and ankle outcome score, visual analog scale, RAND-36 item health survey, range-of-motion measurements, and Kellgren-Lawrence OA classification. RESULTS: Very good to excellent ankle functional outcome was reported by 96% of the stable fracture group [mean Olerud-Molander ankle score (OMAS), 92; range, 20-100] and 82% of the unstable group (mean OMAS, 86; range, 30-100). For patients with an unstable fracture, OMAS and VAS pain scores significantly improved from 2 to 12 years, even though higher grades of radiologic OA were found. No patients with fractures deemed stable needed operative intervention even in the long-term follow-up. Instead, 30% of the operatively treated patients underwent reoperation during the long follow-up. CONCLUSIONS: The treatment of ankle fractures based on stability-based classification led to predictable, functionally good outcomes even during long-term follow-up. Ankle fractures can reliably be deemed stable based on this classification and treated without failures in the long term. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Suture button versus syndesmosis screw fixation in pronation-external rotation ankle fractures: A minimum 6-year follow-up of a randomised controlled trial.

OBJECTIVE: Randomised controlled trials (RCT) with short-term follow-ups have shown that, in treatment of syndesmosis injuries, a suture button device (SB) resulted in better radiographic and functional outcome compared to syndesmosis screw fixation (SS). However, only one RCT has reported long-term results; thus, the syndesmosis malreduction rates for both implants might increase during longer follow-up. The primary objective of this RCT was to evaluate the maintenance of syndesmosis reduction with the SS compared to the SB fixation in patients during a minimum follow-up of 6-years. The secondary objectives were to assess the post-traumatic osteoarthritis (OA) grade and the functional outcome. PATIENTS AND METHODS: At Oulu University Hospital, between January 2010 and December 2011, we enrolled 43 patients with Lauge-Hansen pronation-external rotation type 4/Weber C, ankle fractures with unstable syndesmosis. Patients were randomised to treatment with either a single 3.5-mm tricortical SS (22 patients) or an SB (21 patients). The mean follow-up was 7.1 years (range, 6.2-7.9). Syndesmosis reduction and OA grade was assessed with standing cone-beam computed tomography (CBCT) of both ankles. Malreduction was defined as >2 mm side-to-side difference in the mean width of the syndesmosis. OA was graded according to the Morrey & Wiedeman classification. The Olerud-Molander Ankle Outcome Score (OMAS) and a quality of life questionnaire (RAND 36-Item Health Survey) were used to evaluate functional outcome. RESULTS: Two syndesmoses in the SS group and one in the SB group were malreduced (P = 0.58). Moderate OA after a mean of 7 years post-injury was common. In the SS and SB groups, 9 of 16 and 11 of 13 patients, respectively, had one or more grades serious OA in the injured ankle than in the uninjured ankle (P = 0.11). The mean OMAS was 88 in the SS group and 78 in the SB group (difference between means 7.1, 95% CI: -7.0-21.1, P = 0.32). The RAND-36 results did not differ between groups. CONCLUSION: The SS and SB maintained syndesmosis reduction equally well during follow-up. Our study findings also suggest that both methods result in moderate OA rates and the functional outcome is comparable between these two syndesmosis fixation methods.

Arthroscopic Bankart repair: results and risk factors of recurrence of instability.

The purpose of this study was to discover the recurrence rate of instability after arthroscopic Bankart repair and to assess risk factors for recurrence, with special interest in bone defects seen on preoperative plain radiographs. Consecutive unselected patients (182; 186 shoulders) with recurrent instability (redislocation or subluxation) after initial traumatic anteroinferior shoulder dislocation were operated on using arthroscopic suture-anchor repair at our institution during 2000-2005. Demographic data and details of the operation were retrospectively reviewed from case records, and glenoid and Hill-Sachs lesions were assessed from preoperative radiographs. The primary outcome measure was recurrence of instability (redislocation or subluxation). Functional results were assessed via Oxford instability scores and subjective shoulder values (SSVs), using postal questionnaires. One hundred and seventy-four shoulders (170 patients) were assessed after a median of 51 (range 24-95) months' follow-up. The recurrence rate of instability was 19% (redislocation 9% and subluxation 10%). Eighteen patients (10%) needed further surgery. The mean Oxford instability score was 21 and the mean SSV 84%. The recurrence rate among patients aged 20 or less was 44% and among patients over 20, 12%. Multivariate logistic regression analysis showed that age ≤20 (OR 8.8), Hill-Sachs lesion (OR 3.3), glenoid erosion (OR 2.7) and length of follow-up (OR 1.5) were the most important risk factors for recurrence. Young age is the most important risk factor for recurrence of instability after arthroscopic suture-anchor Bankart repair. Bone defects seen in preoperative plain radiographs are less important and more accurate imaging is needed to reveal their true role for recurrence of instability.

Risk factors for complications after volar plate fixation of distal radial fractures.

This study assessed risk factors for complications after volar plate fixation of distal radial fractures. An assessment of electronic patient records from 2008 to 2016 identified 867 patients with a total of 881 distal radial fractures who underwent volar plating in our hospital. A total of 132 complications after volar plate fixation of distal radial fractures were observed (complication rate 15%). Surgery performed by a low-volume surgeon and patient age less than 40 years were the most important risk factors for plate-related complications. In logistic regression analysis, operation performed by a low-volume surgeon and patient age less than 40 years were independent predictors of plate-related complications. Patient age less than 40 years and low-volume surgeon were also found to be independent risk factors for plate-related secondary operations. Surgical delay had no effect on the complication rate. Level of evidence: IV.