Risk stratification-based thromboprophylaxis does not affect mortality after fast-track hip and knee arthroplasty.

BACKGROUND AND PURPOSE: Use of thromboprophylaxis effectively prevents pulmonary embolism (PE) and deaths after total hip and knee arthroplasty (THA and TKA). The optimum length of thromboprophylaxis is not known and has traditionally been based on the type of operation. Nowadays, a more individualized approach is preferred. This study analyzed if risk stratification-based planning of thromboprophylaxis has an association with the all-cause mortality after fast-track THA and TKA. PATIENTS AND METHODS: We compared fast-track THAs and TKAs operated between 2015-2016 and 2020-2021. Between 2015 and 2016, all patients received a routine length of thromboprophylaxis. From 2020 onwards, thromboprophylaxis was planned by risk stratification, and patients at low risk for venous thromboembolism received thromboprophylaxis only during hospitalization. All causes of death within 90 days of surgery were identified and the incidence of mortality was calculated. Mortality rates between the two periods were then compared. RESULTS: Between 2015 and 2016, 3192 arthroplasties were performed. A total of eight deaths occurred within 90 days of surgery, yielding an incidence of all-cause mortality of 0.3% (95% CI 0.1-0.5). Between 2020 and 2021, a total of 3713 arthroplasties were performed to patients who received risk stratification-based thromboprophylaxis. Thirteen of these patients died within 90 days of surgery, yielding an all-cause mortality incidence of 0.4% (95% CI 0.2-0.6). Cardiovascular diseases were the main cause of death during both study periods. None of the deaths were caused by PEs. INTERPRETATION: Risk stratification-based thromboprophylaxis was not associated with increased all-cause mortality within 90 days of fast-track THA and TKA.

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.

Surgery with locking plate or hemiarthroplasty versus nonoperative treatment of 3-4-part proximal humerus fractures in older patients (NITEP): An open-label randomized trial.

BACKGROUND: Proximal humerus fractures (PHFs) are common fractures, especially in older female patients. These fractures are commonly treated surgically, but the consensus on the best treatment is still lacking. METHODS AND FINDINGS: The primary aim of this multicenter, randomized 3-arm superiority, open-label trial was to assess the results of nonoperative treatment and operative treatment either with locking plate (LP) or hemiarthroplasty (HA) of 3- and 4-part PHF with the primary outcome of Disabilities of the Arm, Shoulder, and Hand (DASH) at 2-year follow-up. Between February 2011 and December 2019, 160 patients 60 years and older with 3- and 4-part PHFs were randomly assigned in 1:1:1 fashion in block size of 10 to undergo nonoperative treatment (control) or operative intervention with LP or HA. In total, 54 patients were assigned to the nonoperative group, 52 to the LP group, and 54 to the HA group. Five patients assigned to the LP group were reassigned to the HA group perioperatively due to high comminution, and all of these patients had 4-part fractures. In the intention-to-treat analysis, there were 42 patients in the nonoperative group, 44 in the LP group, and 37 in the HA group. The outcome assessors were blinded to the study group. The mean DASH score at 2-year follow-up was 30.4 (standard error (SE) 3.25), 31.4 (SE 3.11), and 26.6 (SE 3.23) points for the nonoperative, LP, and HA groups, respectively. At 2 years, the between-group differences were 1.07 points (95% CI [-9.5,11.7]; p = 0.97) between nonoperative and LP, 3.78 points (95% CI [-7.0,14.6]; p = 0.69) between nonoperative and HA, and 4.84 points (95% CI [-5.7,15.4]; p = 0.53) between LP and HA. No significant differences in primary or secondary outcomes were seen in stratified age groups (60 to 70 years and 71 years and over). At 2 years, we found 30 complications (3/52, 5.8% in nonoperative; 22/49, 45% in LP; and 5/49, 10% in HA group, p = 0.0004) and 16 severe pain-related adverse events. There was a revision rate of 22% in the LP group. The limitation of the trial was that the recruitment period was longer than expected due to a high number of exclusions after the assessment of eligibility and a larger exclusion rate than anticipated toward the end of the trial. Therefore, the trial was ended prematurely. CONCLUSIONS: In this study, no benefit was observed between operative treatment with LP or HA and nonoperative treatment in displaced 3- and 4-part PHFs in patients aged 60 years and older. Further, we observed a high rate of complications related to operative treatments. TRIAL REGISTRATION: ClinicalTrials.gov NCT01246167.

Evidence for the in vivo existence and mobilisation of myeloid angiogenic cells and pericyte-like cells in wound patients after skin grafting.

Myeloid angiogenic cells (MACs) and pericyte-like cells, derived from peripheral blood mononuclear cells (MNCs) by in vitro culturing, are suggested as relevant cell types for angiogenesis and tissue repair. However, the in vivo existence and relevance of these cells has so far remained unknown. Our aim was thus to study, if MACs and pericyte-like cells exist in circulation during the wound healing of skin graft patients, and to evaluate the cellular features of wound repair. MNCs were isolated from blood samples of healthy controls (n = 4) and patients with a traumatic full thickness skin defect (n = 4) before skin grafting and on postoperative days 1 and 6. The numbers of circulating CD14+ CD45+ CD31+ CD34- MACs and CD14+ CD45+ NG2+ pericyte-like cells were assessed by flow cytometry, and gene expression of various pro-angiogenic factors was analysed by qPCR. Wound bed biopsies were taken on postoperative days 6 and 14, and MAC (CD31, CD14 and CD45) and pericyte-related markers (NG2 and PDGFRß) were histologically studied. MACs and pericyte-like cells were detected in both healthy controls and in patients. Before reconstruction, on average 18% of all circulating MNCs represented MACs and 2% pericyte-like cells in wound patients. Number of MACs significantly increased 1.1-1.7-fold in all patients 1 day after skin grafting (p < 0.01). In addition, histological analysis demonstrated effective vascularization of skin grafts, as well as presence of pericytes, and CD14 and CD45 expressing myeloid cells during wound healing. In conclusion, our data shows, for the first time, the presence and mobilisation of MACs and pericyte-like cells in human circulation.

Effect of national COVID-19 lockdown on the incidence of muscle, tendon and ligament injuries and related surgical procedures in the working-aged Finnish population.

INTRODUCTION: The effect of lockdown on the incidence of fractures and severe injuries has been widely studied, whereas studies regarding muscle, tendon, and ligament injuries have not received as much attention. The aim of the study was to investigate the effect of the lockdown and later regional regulations due to the COVID pandemic on the incidence of muscle, tendon, and ligament injuries and related surgical procedures. MATERIALS AND METHODS: This study focuses on the working-age population in the catchment areas of three major Finnish hospitals. Patients were divided into three age groups 18-34, 35-50 and 51-65 years of age. Suitable injuries were retrieved from the data using appropriate ICD-10 codes and procedure codes. The monthly incidence rate ratio (IRR), with 95% confidence intervals (CI), were compared between the year 2020 and the reference years 2017-2019. RESULTS: Upper and lower extremity injury ED visits decreased by 15.7 and 8.2%. For upper extremity injuries, a decrease in incidence was observed for all three age groups in March (IRR 0.52, CI 0.33-0.80), (IRR 0.53, CI 0.31-0.91), (IRR 0.60, CI 0.38-0.95), respectively. An increase in 18-34 years of age group was detected in June (IRR 1.49, CI 1.05-2.13). Lower extremity injuries decreased in 18-34 years of age group in March (IRR 0.62, CI 0.43-0.90) and April (IRR 0.60, CI 0.42-0.87). A decrease on the incidence of surgeries was observed in April for the 35-50 (IRR 0.53, CI 0.29-0.97) and 51-65 years of age groups (IRR 0.58, CI 0.34-0.98). CONCLUSIONS: The nationwide lockdown in spring 2020 led to a notable decrease in the incidence of emergency department visits and the surgical treatment of muscle, tendon, and ligament injuries in Finland.

Venous thromboembolism is rare after total hip and knee joint arthroplasty with long thromboprophylaxis in Finnish fast-track hospitals.

INTRODUCTION: Pharmacological thromboprophylaxis effectively prevents venous thromboembolism (VTE) after total knee (TKA) and total hip arthroplasty (THA). Less is known about the influence of fast-track arthroplasty on VTE risk. We conducted a register-based study to determine the incidence of VTE after fast-track TKA and THA in Finland using long thromboprophylaxis. MATERIALS AND METHODS: All primary TKAs and THAs operated during 2015-2016 in 3 fast-track hospitals were identified from the Finnish Arthroplasty Register. Pulmonary embolism (PE) and deep vein thrombosis (DVT) diagnosed in this patient cohort within 90 days of surgery were identified from the Finnish Hospital Discharge Register. The recommended length of thromboprophylaxis was 10 to 14 days for TKA and 28 days for THA during study period. RESULTS: During the study period, 3 831 THAs, 4 394 TKAs and 286 bilateral TKAs (BTKAs) were performed. Of all these patients, 60% were females. Venous thromboembolism (VTE) incidence within 90 days of surgery was 0.3% (95% CI 0.2-0.4). These VTEs comprised 10 PEs and 15 DVTs. None of the VTE patients´ died within the 90-day period. CONCLUSION: VTE incidence is low in Finnish fast-track TKA and THA patients with long thromboprophylaxis.

The Development of Lower Limb Amputations in Finland from 1997 to 2018: A Nationwide Retrospective Registry Study.

OBJECTIVE: To investigate the rates of transfemoral, transtibial foot and toe amputations, and lower limb revascularisations in Finland between 1997 and 2018. METHODS: Retrospective observational cohort study. Data from the Finnish National Hospital Discharge Register for the period 1997 - 2018 were used. The study population covered all patients 20 years and older who underwent lower limb revascularisations or amputations in private and public hospitals during the study period. All (outpatient and inpatient) amputations and revascularisations were included. The age adjusted incidence rates were based on the annual mid populations, which were obtained from the Official Statistics of Finland. Continuous variables were presented as median with interquartile range (IQR) or as mean with standard deviation. The 95% confidence intervals (CI) for the incidence rates were calculated using the Poisson exact method. All changes in incidence were calculated as relative change (%). RESULTS: A total of 75 230 patients underwent 149 492 lower limb revascularisations and amputations between 1997 and 2018 in Finland. The median (IQR) age of the patients was 73 (65, 80) and 60% of the patients were men. The incidence of all endovascular lower limb revascularisations increased by 159% while the incidence of lower limb amputations increased by 25%. The most notable increase occurred in toe (84%) and foot (107%) amputations, while the incidence of transfemoral amputations remained steady and transtibial amputations decreased by 53%. The first minor-major amputation ratio (CI) increased from 1.13 (1.03 - 1.24) to 1.49 (1.36 to 1.62) during the study period. CONCLUSION: The findings of this nationwide cohort study suggest that the incidence of both lower limb revascularisations and amputations is increasing. More specifically, revascularisations are more often performed endovascularly, and the incidence of transtibial amputations is declining, whereas the incidence of toe and foot amputations is increasing.

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.

Distal biceps tendon repairs and reconstructions-an analysis of demographics, prodromal symptoms and complications.

INTRODUCTION: The purpose of this study was to evaluate the demographics, complications and prodromal symptoms (any pain or unpleasant sensation in the area distal biceps tendon preceding the injury) of distal biceps tendon tears (DBTTs) of patients treated with primary repair or Achilles allograft reconstruction. MATERIALS AND METHODS: 228 consecutive DBTTs in 226 patients from a single centre were evaluated. The demographic data, prodromal symptoms and postoperative adverse events were documented. RESULTS: There were 225 males and 1 female patient. The age distribution showed a bimodal pattern in the whole cohort, but once the 48 (20%) elite athletes were excluded, the age was normally distributed, peaking in the 5th decade. Direct repairs were performed in 184 cases and reconstruction with Achilles tendon allograft in 45 cases. An adverse event was observed in 34 (19%) patients who underwent direct repair and in 3 (7%) cases with graft reconstruction, corresponding to RR of 0.32 (95% CI 0.1-0.96, p = 0.04). Adjusting with the potential confounders (age, occupation and smoking), the OR was 0.35; 95% CI 0.09-1.3, p = 0.11). Adverse events included 28 (12.3% of all adverse events) lateral antebrachial cutaneous nerve (LABCN) neurapraxias, 5 (2.1%) other neurapraxias, 6 (2.6%) heterotopic ossifications and 1 (0.4%) re-rupture. Twenty-three (10%) patients reported prodromal symptoms before the tear. CONCLUSIONS: DBTT is a condition that affects men predominantly. The observed bimodal incidence distribution was related to elite athletes, but in the normal population the peak occurs at the age typical to tendinopathies. LABCN neurapraxia was the most common adverse event, and graft use does not seem to predispose to adverse events.

Rapid rise in prevalence of knee replacements and decrease in revision burden over past 3 decades in Finland: a register-based analysis.

BACKGROUND AND PURPOSE: The prevalence of knee joint replacements (KJR) has been less investigated in situations where the increase in incidence is known. This study investigated the annual and population-based prevalence of KJR and the relationship between the prevalence of KJRs and the incidence of revision surgery. PATIENTS AND METHODS: All KJRs performed between 1980 and 2020 were identified from the Finnish Arthroplasty Register (FAR). KJR revisions and removals were extracted from the FAR and hospital discharge registers and patient deaths from Finnish Digital and Population Data Services Agency. We analyzed the annual prevalence by dividing the number of KJR survivors by the population aged 40 or older. The revision burden factor (RBF) was determined by dividing the annual number of revisions by the number of primary and revision KJRs in the population. Proportions of bilateral implants and patients with older KJRs performed 10 or more years earlier were identified. RESULTS: KJR prevalence in Finland increased by 298% between 2000 and 2020, reaching 4.0% in 2020. The proportion of patients with bilateral KJRs and those with older KJRs had increased to 37% and 34%, respectively, by 2020. The annual RBF decreased statistically significantly from 1.9% to 0.7% between 1996 and 2020 (proportion ratio, PR 0.37 [95% CI 0.33-0.42]) and was higher among males (PR 1.23 [CI 1.20-1.26]). INTERPRETATION: Although the recent rapid increase in KJRs is abating and the RBF is diminishing, it is important to take the continuing increase in the prevalence of KJRs into account when assessing hospitals' future resources.

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.

Decreased burden of revision hip replacements despite substantial rise in prevalence: a register-based analysis in Finland.

BACKGROUND AND PURPOSE: While the incidence of THR operations has been established, little is known about the prevalence or the ratio of the annual number of revision THRs to the total number of THRs in the general population. By combining data from nationwide registers, we calculated the annual prevalence of THRs and the revision burden caused by THR survivors in Finland. PATIENTS AND METHODS: All primary THRs performed between 1980 and 2020 were identified from the Finnish Arthroplasty Register (FAR). Patient deaths were extracted from the Finnish Digital and Population Data Services Agency and THR revisions and removals from the FAR and the Finnish Hospital Discharge Register. We analyzed annual THR prevalence by dividing the number of THRs by the population aged 40 or older and the revision burden factor (RBF) by dividing the annual number of revisions by the total number of primary and revision THRs in the population. The proportions of bilateral implants and patients with THRs performed more than 10 years earlier (older THRs) were identified. RESULTS: THR prevalence in Finland increased rapidly, reaching 3.6% in 2020. Between 2010 and 2020, the number of THRs increased by 50% and the prevalence of THRs by 38%. In 2020, the proportion of bilateral THRs had risen to 29% and the proportion of patients with older THRs to 36%. The RBF decreased between 1996 and 2020 from 3.1% to 1.3% (age- and sex-adjusted proportion ratio PR 0.42 [95% CI 0.39-0.45]). INTERPRETATION: Despite the decrease in the RBF, the rapidly increasing prevalence of THRs potentially increases the number of revisits and revisions and thus poses a challenge for healthcare in the future.

Low incidence of clinically relevant bleeding complications after fast-track arthroplasty: a register study of 8,511 arthroplasties.

BACKGROUND AND PURPOSE: Fast-track total joint replacement (TJR) has become increasingly common. Routine thromboprophylaxis for pulmonary embolism and deep venous thrombosis prevention lasts from 2 to 5 weeks. This retrospective registry study focused on clinically relevant bleeding complications 90 days after fast-track primary TJR. PATIENTS AND METHODS: All primary fast-track total hip (THA) and knee arthroplasties (TKA) performed between 2015 and 2016 were extracted from the Finnish Arthroplasty Register and Finnish Hospital Discharge Register. Type of arthroplasty and indication for the operation were combined with diagnoses of clinically relevant bleeding complications within 90 days of surgery. The incidence of these bleedings was the primary outcome measure. RESULTS: Of the total of 8,511 patients (mean age 67 years (SD 10); 60% female), 45% underwent unilateral THA, 52% unilateral TKA, and 3% bilateral TKA. The incidence of clinically relevant bleeding complications within 90 days was 1% (95% CI 0.8-1.3). No difference was observed in bleeding incidence between the groups. The 87 bleedings comprised 57 operative site bleedings, 17 gastrointestinal bleedings, 6 intracranial non-traumatic bleedings, 5 bleedings from the nose or another undetermined site, and 2 intraocular bleedings. 1 death due to intracranial bleeding was recorded, and hence clinically relevant bleeding-specific 90-day mortality was 0.01%. INTERPRETATION: The incidence of clinically relevant bleeding complications was low. However, they cause patient discomfort, increase the use of healthcare services, and can be life-threatening and even fatal.

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.

Non-uniform displacement within ruptured Achilles tendon during isometric contraction.

The purpose of this study was investigate tendon displacement patterns in non-surgically treated patients 14 months after acute Achilles tendon rupture (ATR) and to classify patients into groups based on their Achilles tendon (AT) displacement patterns. Twenty patients were tested. Sagittal images of AT were acquired using B-mode ultrasonography during ramp contractions at a torque level corresponding to 30% of the maximal isometric plantarflexion torque of the uninjured limb. A speckle tracking algorithm was used to track proximal-distal movement of the tendon tissue at 6 antero-posterior locations. Two-way repeated measures ANOVA for peak tendon displacement was performed. K-means clustering was used to classify patients according to AT displacement patterns. The difference in peak relative displacement across locations was larger in the uninjured (1.29 ± 0.87 mm) than the injured limb (0.69 ± 0.68 mm), with a mean difference (95% CI) of 0.60 mm (0.14-1.05 mm, P < .001) between limbs. For the uninjured limb, cluster analysis formed 3 groups, while 2 groups were formed for the injured limb. The three distinct patterns of AT displacement during isometric plantarflexion in the uninjured limb may arise from subject-specific anatomical variations of AT sub-tendons, while the two patterns in the injured limb may reflect differential recovery after ATR with non-surgical treatment. Subject-specific tendon characteristics are a vital determinant of stress distribution across the tendon. Changes in stress distribution may lead to variation in the location and magnitude of peak displacement within the free AT. Quantifying internal tendon displacement patterns after ATR provides new insights into AT recovery.

Surgery for patellar dislocation has evolved towards anatomical reconstructions with assessment and treatment of anatomical risk factors.

PURPOSE: Increasing knowledge on the treatment of patellar dislocation has resulted in the development of new surgical techniques for patella stabilisation. National incidence and trends in surgery for patellar dislocation were examined using data from the Finnish National Hospital Discharge Register (NHDR). The hypothesis was that an increased understanding of the pathophysiology of patellar instability has increased the popularity of reconstructing damaged structures and modification of anatomical risk factors. METHODS: Data from the years 1997-2016 were collected from the NHDR database using ICD-10 diagnostic codes and the Nomesco Classification of Surgical Procedures (NCSP) codes. Surgical procedures were categorised into subgroups representing the main surgical approaches of patellar dislocation. Total incidence of surgery for patellar dislocation and change in incidence during the study period were calculated. RESULTS: A total of 9702 operations for patellar dislocation were performed during the study period. Median (IQR) patient age at time of primary surgery was 23 (18-34) years. The total incidence of surgeries remained stable across the study period at of 8.9 per 100,000 person-years. Incidences of ligament reconstruction, femoral osteotomies and osteochondral fragment reimplantation operations multiplied during the study period. Ligament reconstruction procedures were the most performed operations at the end of the study period. CONCLUSION: The incidence of surgical procedures for patellar dislocation remained unchanged during the years 1997-2016. Ligament reconstruction procedures increased in popularity. Surgical techniques have shifted towards the reconstruction of damaged structures and the modification of congenital anatomical risk factors for patellar dislocation. Diversified surgical techniques have enabled the tailoring and combining of stabilizing procedures according to the patient's individual anatomy.

The risk of osteochondral fracture after patellar dislocation is related to patellofemoral anatomy.

PURPOSE: Despite the comprehensive literature on the anatomical risk factors for patellar dislocation, knowledge on the risk factors for subsequent osteochondral fracture (OCF) remains limited. METHODS: Magnetic resonance imaging was used to compare measures of patellofemoral anatomy in patients with OCF after patellar dislocation and propensity score matched patients without OCF. For differing measures, limit values showing a 50% probability for the occurrence of OCF were calculated using predictive logistic regression modelling. Proportions of abnormal measures in the groups were compared using Chi-square test. The association of anatomical measures with OCF location was examined by comparing subgroup mean values in the different OCF locations. RESULTS: Propensity score matching provided a total of 111 matched pairs of patients with OCF and patients without OCF. The patients with and without OCF differed in patellotrochlear index (PTI; 0.54 [95% CI 0.52-0.57] vs. 0.47 [95% CI 0.45-0.49]; p < 0.001), tibial tubercle-posterior cruciate ligament distance (TT-PCL; 21.6 mm [95% CI 21.0-22.3 mm] vs. 20.5 mm [95% CI 20.0-21.1 mm]; p = 0.013), trochlear depth (2.5 mm [95% CI 2.3-2.7 mm] vs. 3.0 mm [95% CI 2.8-3.2 mm]; p < 0.001) trochlear facet asymmetry ratio (0.54 [95% CI 0.51-0.57] vs. 0.43 [95% CI 0.42-0.45]; p < 0.001) and trochlear condyle asymmetry ratio (1.04 [95% CI 1.03-1.04] vs. 1.05 [95% CI 1.04-1.05]; 0.013. Thresholds for increased OCF risk were > 0.51 for PTI > 21.1 mm for TT-PCL < 2.8 mm for trochlear depth > 0.48 for trochlear facet asymmetry ratio and < 1.04 for trochlear condyle asymmetry ratio. CONCLUSION: In patients with OCF after patellar dislocation, trochlear configuration and patella vertical location were closer to normal anatomy, whereas patella lateralization was more severe when compared to patients without OCF. These anatomical factors contribute to the risk of OCF during patellar dislocation. LEVEL OF EVIDENCE: III.

Effects of progressive aquatic resistance training on symptoms and quality of life in women with knee osteoarthritis: A secondary analysis.

OBJECTIVE: To conduct a secondary analysis to study the effects, those 4 months of aquatic resistance training have on self-assessed symptoms and quality of life in post-menopausal women with mild knee osteoarthritis (OA), after the intervention and after a 12-month follow-up period. METHODS: A total of 87 post-menopausal volunteer women, aged 60-68 years, with mild knee OA were recruited in a randomized, controlled, 4-month aquatic training trial (RCT) and randomly assigned to an intervention (n = 43) and a control (n = 44) group. The intervention group participated in 48 supervised aquatic resistance training sessions over 4 months while the control group maintained their usual level of physical activity. Additionally, 77 participants completed the 12-month post-intervention follow-up period. Self-assessed symptoms were estimated using the OA-specific Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and Health-related Quality of life (HRQoL) using the generic Short-form Health Survey (SF-36). RESULTS: After 4 months of aquatic resistance training, there was a significant decrease in the stiffness dimension of WOMAC -8.5 mm (95% CI = -14.9 to -2.0, P = .006) in the training group compared to the controls. After the cessation of the training, this benefit was no longer observed during the 12-month follow-up. No between-group differences were observed in any of the SF-36 dimensions. CONCLUSIONS: The results of this study show that participation in an intensive aquatic resistance training program did not have any short- or long-term impact on pain and physical function or quality of life in women with mild knee OA. However, a small short-term decrease in knee stiffness was observed.

Enhanced rehabilitation guidance after arthroscopic capsulolabral repair of the shoulder: a randomized controlled trial.

OBJECTIVE: To compare the effects of a 12-month home-based exercise program to usual care in patients after arthroscopic capsulolabral repair of the shoulder. DESIGN: Randomized controlled trial. SETTING: Outpatient physical and rehabilitation medicine clinic. SUBJECTS: Forty-five patients (mean age: 35 years; standard deviation (SD): 10 years) who underwent arthroscopic capsulolabral repair due to labral lesion were randomized into an exercise group (EG) or a control group (CG). INTERVENTION: The EG received a 12-month home-based additional exercise program with four physiotherapy follow-up visits, while the CG received standard postoperative exercise instructions. MAIN MEASURES: Self-reported shoulder disability was assessed with the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and quality of life with the Short-Form (SF)-36 Health Survey. The function of the operated shoulder was evaluated with strength and range of motion measurements. RESULTS: No between-group differences were observed in any of the outcomes at the follow-up. Mean ASES score improved by 16 (95% confidence interval (CI): 10-23) points from the baseline 78 (SD: 17) in the EG and 13 (95% CI: 7-19) points from the baseline 79 (SD: 17) in the CG. Both groups achieved a significant improvement in the dimensions of Physical Functioning, Role-Physical, and Bodily Pain of the SF-36 and in every aspect of strength and range of motion measures. In EG, exercise adherence was moderate (52%) during the first six months and poor (22%) during the last six months. CONCLUSION: Home-based additional exercises with four outpatient follow-up visits did not improve outcome after arthroscopic capsular repair of the shoulder.

Factors explaining heterogeneity in studies comparing surgical and nonsurgical treatment of midshaft clavicle fractures: a meta-regression analysis of randomized controlled trials and high-quality observational studies.

BACKGROUND: Previous meta-analyses comparing the surgical and nonsurgical treatment of midshaft clavicle fractures have demonstrated extensive heterogeneity, that is, treatment effect variation, in different pooled outcomes. We aimed to investigate the amount of heterogeneity seen in pooled treatment effects and to explore which moderator variables serve to explain this heterogeneity. METHODS: A follow-up literature search, based a previous study, was conducted. All randomized controlled trials and high-quality observational studies with suitable treatment cohorts were identified and included in this systematic review and meta-regression analysis. The proportions of male patients, patients with the dominant hand injured, and smokers, as well as fracture type and mean age, were included as covariates in meta-regression analyses investigating the effect on the pooled estimate of treatment effect heterogeneity. The pooled treatment effects assessed were nonunion rate, malunion rate, Disabilities of the Arm, Shoulder and Hand score, and Constant score at 1 year, as well as revision surgery rate. RESULTS: High heterogeneity was observed in 4 of 8 pooled treatment effects and moderate, in 2 of 8. An association between any of the covariates, including smoking, with the pooled treatment effect for the nonunion rate could not be established. Regarding malunion, the proportion of patients with the dominant hand injured showed linear dependency with the risk ratio. The proportion of male patients correlated with the pooled mean difference in both the Disabilities of the Arm, Shoulder and Hand score and Constant score. Mean age and fracture type correlated with the pooled mean difference in the Constant score. CONCLUSION: On the basis of our results, several potential moderators influence the treatment effect when comparing surgical and nonsurgical treatment of midshaft clavicle fractures. These findings have implications for shared decision making and when making treatment recommendations.