Risk Factors for Upper Extremity Refractures in Children.

BACKGROUND: Multiple descriptive studies have been published on refracture patterns, particularly for forearm fractures. However, few large cohorts have been analyzed quantitatively including the odds of refracture, and with a comprehensive assessment of the possible predictive factors associated with refracture. This study aimed to assess the frequency and timing of upper extremity refracture in a large pediatric orthopaedics practice, and to evaluate the strength of association of various patient-level and fracture-related factors with refracture. METHODS: Medical records were reviewed retrospectively for patients 1 to 18 years of age with at least 1 upper extremity fracture (ICD-9 codes 810 to 819) between June 1, 2010 and May 31, 2011. Characteristics of patients and fractures were assessed for the association with refracture using bivariate analysis and multivariable logistic regression. RESULTS: Among 2793 patients with a total of 2902 upper extremity fractures, 2% were treated for refracture within 2 years, at a median of 6 months (188 d) after the initial injury. Midshaft location, and characterization of the fracture as angulated or buckle, were associated with being more likely to refracture. Eighty percent of refractures were the result of a fall, with almost 25% involving a high-energy mechanism and about 15% from monkey bars or other playground equipment. The adjusted odds of refracture were 4 times higher if noncompliance with treatment recommendations was documented, when controlling for insurance type and number of days before orthopaedic evaluation. Forearm fractures were almost 4 times more likely to refracture compared with other bones, controlling for midshaft location, days immobilized, and buckle or torus characterization of the fracture. CONCLUSIONS: Our practice saw a refracture occurrence in 2% of patients, with median time to refracture of ~6 months. The factors most strongly associated with refracture were midshaft fracture location, forearm fracture as opposed to clavicle or humerus, and noncompliance as defined in the study. Falls and high energy activities, such as use of wheeled devices, skis, or trampolines, were important mechanisms of refracture. LEVEL OF EVIDENCE: This study is a Level II prognostic study. It is a retrospective study that evaluates the effect of patient and fracture characteristics on the outcome of upper extremity refracture.

The risk of ureteric injury associated with hysterectomy: a 10-year retrospective cohort study.

OBJECTIVE: To evaluate the rates of ureteric injury among women undergoing hysterectomy. DESIGN: Retrospective cohort. SETTING: English National Health Service hospitals. POPULATION: Women undergoing hysterectomy in 2001-2010. METHODS: Unadjusted rates of ureteric injury, within 1 year of hysterectomy, calculated by indication and type of procedure. Multivariable logistic regression used to assess the risk of ureteric injury with year of surgery. MAIN OUTCOME MEASURES: Ureteric injury within a year of the hysterectomy. RESULTS: In 2001-2010, 377 073 women underwent hysterectomy, of whom 1792 (0.5%) experienced a ureteric injury. In both benign and malignant groups the rate of injury was higher in 2006-2010 than 2001-2005. After 2006, ureteric injuries were most common for abdominal radical hysterectomy for uterine cancer (10.7%; 95% CI 7.3-15.1%). The proportion of women having a ureteric injury was similar for ovarian and cervical cancer (1.9-4.0% depending on type of procedure). For benign conditions, the rate of injury tended to be lower, typically <1%. Women with endometriosis had the highest risk among this group (1.7% following total abdominal hysterectomy; 95% CI 1.4-2.0%). CONCLUSION: The risk of ureteric injury within 1 year of hysterectomy varied by type of hysterectomy for benign and malignant conditions. The rates of injury have increased between 2001 and 2010. TWEETABLE ABSTRACT: Ten-year study shows ureteric injury rates have increased.

Identification of Polynesian mtDNA haplogroups in remains of Botocudo Amerindians from Brazil.

There is a consensus that modern humans arrived in the Americas 15,000-20,000 y ago during the Late Pleistocene, most probably from northeast Asia through Beringia. However, there is still debate about the time of entry and number of migratory waves, including apparent inconsistencies between genetic and morphological data on Paleoamericans. Here we report the identification of mitochondrial sequences belonging to haplogroups characteristic of Polynesians in DNA extracted from ancient skulls of the now extinct Botocudo Indians from Brazil. The identification of these two Polynesian haplogroups was confirmed in independent replications in Brazil and Denmark, ensuring reliability of the data. Parallel analysis of 12 other Botocudo individuals yielded only the well-known Amerindian mtDNA haplogroup C1. Potential scenarios to try to help understand these results are presented and discussed. The findings of this study may be relevant for the understanding of the pre-Columbian and/or post-Columbian peopling of the Americas.

Obesity, hypertension, social determinants of health and the epidemiologic transition among traditional Amazonian populations.

BACKGROUND: The health and nutritional situation of adults from three rural vulnerable Amazonian populations are investigated in relation to the Social Determinants of Health (SDH) and the epidemiologic transition. AIM: To investigate the role of the environment and the SDH on the occurrence of chronic-degenerative diseases in these groups. SUBJECTS AND METHODS: Anthropometric, blood pressure and demographic data were collected in adults from the RDS Mamirauá, AM (n = 149), Flona Caxiuanã, PA (n = 148) and quilombolas, PA (n = 351), populations living in a variety of socio-ecological environments in the Brazilian Amazon. RESULTS: Adjusting for the effect of age, quilombola men are taller (F = 9.85; p < 0.001) and quilombola women present with higher adiposity (F = 20.43; p < 0.001) and are more overweight/obese. Men from Mamirauá present higher adiposity (F = 9.58; p < 0.001). Mamirauá women are taller (F = 5.55; p < 0.01) and have higher values of waist circumference and subscapular/triceps index. Quilombolas present higher prevalence of hypertension in both sexes and there are significant differences in rates of hypertension among the women (χ(2) = 17.45; p < 0.01). The quilombolas are more dependent on government programmes, people from Mamirauá have more economic resources and the group from Caxiunã have the lowest SES. CONCLUSION: In these populations, the SDH play a key role in the ontogeny of diseases and the 'diseases of modernity' occur simultaneously with the always present infectoparasitic pathologies, substantially increasing social vulnerability.

Improving diagnostic efficiency: analysis of pelvic MRI versus emergency hip aspiration for suspected hip sepsis.

BACKGROUND: Accurately diagnosing and treating childhood hip sepsis is challenging. Adjacent bone and soft-tissue infections are common and can lead to delayed and inappropriate treatment. This study evaluated the effect of early advanced imaging (bone scan, magnetic resonance imaging) in the management of suspected hip sepsis. METHODS: A retrospective review of pediatric patients admitted between 2003 and 2009 with suspected hip sepsis was performed. Patients were classified into 2 categories: group I-immediate hip aspiration or group II-advanced imaging performed before intervention. RESULTS: In total, 130 patients (53 in group I and 77 in group II) were included. No significant differences were found between the groups with regard to laboratory values, temperature, number of anesthetics, and length of hospital stay. However, patients in group I were younger than in group II (5.4 vs. 7.3 y, P=0.02) and more patients in group I were unable to bear weight on the affected limb compared with group II (83% vs. 61%, P=0.009). In group I, 36 patients (68%) had a septic hip compared with 35 patients (45%) in group II. In group I, 16 patients (30%) required reoperation versus 13 (17%) patients in group II. Results from the multivariate analysis demonstrated that reoperation was required 2.8 times (95% confidence interval, 1.12-6.78) more often in group I as compared with group II (P=0.03). CONCLUSIONS: Advanced imaging performed before hip aspiration improves diagnostic efficacy and may decrease the need for reoperation. LEVEL OF EVIDENCE: III.

Reliability of internal oblique elbow radiographs for measuring displacement of medial epicondyle humerus fractures: a cadaveric study.

BACKGROUND: Standard elbow radiographs (AP and lateral views) are not accurate enough to measure true displacement of medial epicondyle fractures of the humerus. The amount of perceived displacement has been used to determine treatment options. This study assesses the utility of internal oblique radiographs for measurement of true displacement in these fractures. METHODS: A medial epicondyle fracture was created in a cadaveric specimen. Displacement of the fragment (mm) was set at 5, 10, and 15 in line with the vector of the flexor pronator mass. The fragment was sutured temporarily in place. Radiographs were obtained at 0 (AP), 15, 30, 45, 60, 75, and 90 degrees (lateral) of internal rotation, with the elbow in set positions of flexion. This was done with and without radio-opaque markers placed on the fragment and fracture bed. The 45 and 60 degrees internal oblique radiographs were then presented to 5 separate reviewers (of different levels of training) to evaluate intraobserver and interobserver agreement. RESULTS: Change in elbow position did not affect the perceived displacement (P=0.82) with excellent intraobserver reliability (intraclass correlation coefficient range, 0.979 to 0.988) and interobserver agreement of 0.953. The intraclass correlation coefficient for intraobserver reliability on 45 degrees internal oblique films for all groups ranged from 0.985 to 0.998, with interobserver agreement of 0.953. For predicting displacement, the observers were 60% accurate in predicting the true displacement on the 45 degrees internal oblique films and only 35% accurate using the 60 degrees internal oblique view. CONCLUSIONS: Standardizing to a 45 degrees internal oblique radiograph of the elbow (regardless of elbow flexion) can augment the treating surgeon's ability to determine true displacement. At this degree of rotation, the measured number can be multiplied by 1.4 to better estimate displacement. The addition of a 45 degrees internal oblique radiograph in medial humeral epicondyle fractures has good intraobserver and interobserver reliability to more accurately estimate the true displacement of these fractures. LEVEL OF EVIDENCE: Diagnostic study, Level II (Development of diagnostic study with universally applied reference "gold" standard).

The risk of vesicovaginal and urethrovaginal fistula after hysterectomy performed in the English National Health Service--a retrospective cohort study examining patterns of care between 2000 and 2008.

OBJECTIVE: To estimate rates of vesicovaginal and urethrovaginal fistula among women undergoing hysterectomy by indication and type of procedure, and to assess trends in risk over time. DESIGN: Retrospective cohort using data from Hospital Episode Statistics. SETTING: English National Health Service (NHS) hospitals. POPULATION: Women undergoing hysterectomy for selected common conditions in English NHS hospitals between January 2000 and December 2008. METHODS: Unadjusted rates of urogenital fistula were calculated by type of procedure and indication. Logistic regression was used to assess whether the risk of fistula was associated with age, or had changed over time. MAIN OUTCOME MEASURE: Rate of urogenital fistula (vesicovaginal and urethrovaginal fistula) within 1 year of hysterectomy. RESULTS: Among 343 771 women undergoing hysterectomy, the overall rate of fistula was 1 in 788. The rate varied by indication and procedure, being highest following radical hysterectomy for cervical cancer (1 in 87; 95% CI 61-128) and lowest following vaginal hysterectomy for prolapse (1 in 3861; 95% CI 2550-6161). After total abdominal hysterectomy for endometriosis, menstrual problems or fibroids, the risk of fistula was lower in women aged 50 years or over than in women under 40 years (adjusted odds ratio 0.61; 95% CI 0.38-0.98). The overall rate of fistula increased by 46% during the study period. CONCLUSIONS: The risk of urogenital fistula was associated with type of hysterectomy and indication; the risk increased during the study period, and was lower after hysterectomy for benign conditions in women aged 50 years or over.

Medial epicondyle fractures in the pediatric population.

Humeral medial epicondyle fractures in the pediatric population account for up to 20% of elbow fractures, 60% of which are associated with elbow dislocation. Isolated injuries can occur from either direct trauma or avulsion. Medial epicondyle fractures also occur in combination with elbow dislocations. Traditional management by cast immobilization increasingly is being replaced with early fixation and mobilization. Relative indications for surgical fixation include ulnar nerve entrapment, gross elbow instability, and fractures in athletic or other patients who require high-demand upper extremity function. Absolute indications for surgical intervention are an incarcerated fragment in the joint or open fractures. Radiographic assessment of these injuries and their true degree of displacement remain controversial.

Focal fibrocartilaginous dysplasia in the ulna: report on 3 cases.

Focal fibrocartilaginous dysplasia is an uncommon, benign bone lesion that causes deformity in young children. It is most commonly encountered in the proximal tibia, with few cases documented in the upper extremity. We report 3 cases affecting the ulna. In each case, the fibrous tissue appeared to anchor itself in the ulnar diaphysis, behaving as a tether that retards growth. All 3 patients had excision of the fibrous tissue. There was concern for radial head subluxation before surgical intervention, but all patients maintained a congruent radiocapitellar articulation. The visible deformity improved in all 3 patients, although the limbs remained shorter than the contralateral side. In our limited series, we believe that early excision of the fibrous tissue tether can prevent radiocapitellar joint dislocation in patients with focal fibrocartilaginous dysplasia of the ulna.

Metacarpal synostosis: treatment with a longitudinal osteotomy and bone graft substitute interposition.

PURPOSE: To describe a case series of congenital metacarpal synostosis treated with longitudinal osteotomy and bone graft substitute interposition. METHODS: We retrospectively reviewed charts of all patients with metacarpal synostosis treated with a longitudinal osteotomy and bone graft substitute interposition at 2 institutions. Radiographic and clinical appearances were analyzed at initial diagnosis, intraoperatively, and at last follow-up. RESULTS: A total of 10 patients (14 hands) met the inclusion criteria. Six patients (8 hands) demonstrated ring-little finger metacarpal synostosis and 4 patients (6 hands) had a middle-ring finger metacarpal synostosis. The median age at operation was 5 years (range, 2-16 y). Follow-up ranged from 1 to 14 years (average, 3 y). Associated hand anomalies included polydactyly, symbrachydactyly, and clinodactyly. Before surgery, the little finger proximal phalanx was angulated away from the middle finger metacarpal on average 46° (range, 26°-60°), and the angulation between the middle and the ring fingers averaged 43° (range, 26°-50°). Postoperative correction at 1 year was statistically significant for both ring-little finger metacarpal synostosis, average 23° (range, 10°-30°), and middle-ring finger metacarpal synostosis, average 16° (range, 5°-44°). Recurrence of digital abduction was evident in 2 patients who had middle-ring finger metacarpal synostosis. CONCLUSIONS: Metacarpal synostosis is an uncommon congenital hand anomaly characterized by the coalescence of 2 adjacent metacarpals. In the most common form, the ring and little finger metacarpals are associated with abduction of the small finger in an awkward position. Use of the described technique is safe and effective, yet concerns remain regarding mild persistent angulation and risk of recurrence. CLINICAL RELEVANCE: Congenital metacarpal synostosis may be effectively treated with a longitudinal osteotomy, realignment of component metacarpals, and interposition of bone graft substitute. When the procedure is performed at a young age, we recommend follow-up until skeletal maturity to identify recurrence of the deformity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Effect of osteochondroma location on forearm deformity in patients with multiple hereditary osteochondromatosis.

PURPOSE: Multiple hereditary osteochondromatosis (MHO) is an autosomal-dominant skeletal dysplasia that may result in forearm deformity. The purpose of this study was 2-fold: to describe the natural history of forearm deformity in patients with MHO, with particular attention to those who develop radial head dislocation, and to determine predictors of deformity. METHODS: We retrospectively reviewed charts of all patients with MHO evaluated at our institution. Patients with the presence of a radiographically visible osteochondroma in the forearm were divided into 5 groups or types based on location of the osteochondroma(s). Radiographic measurements included radial articular angle, percent ulnar variance, radial bow, radial length, ulnar length, and ulnar bow. The predictive values of each measure were statistically evaluated for each type with relation to radial head dislocation. RESULTS: Of 146 patients with MHO, 102 patients (70%) had forearm involvement. Appropriate anteroposterior and lateral radiographs were available on 48 patients (76 forearms). Average age at initial radiographic evaluation was 12 years (range, 2-18 y). Average follow-up period was 7 years (range 1-19 y). Thirteen forearms demonstrated radial head dislocation, with all but 1 reported in the type 1 limbs (solitary distal ulna osteochondroma). Radial head dislocation was noted in 34% (12/35 forearms) of type 1 limbs. CONCLUSIONS: Forearms with isolated osteochondromas of the distal ulna are the ones most likely to develop radial head dislocation. Because the ulna growth is disproportionately less than radial growth, the soft tissues may act as a tether, linking the distal radius and ulna, and lead to radial head dislocation. Changes in radiographic measurements may predict limbs at risk for radial head dislocation.

Ways and detours in guarantee of health for the black population and the confrontation of racism in Brazil. / (Des)caminhos na garantia da saúde da população negra e no enfrentamento ao racismo no Brasil.

Institutional racism is prevalent in the health services in Brazil and is based on concrete power relations that subjugate, dominate and exclude blacks from having adequate access to health care and health institutions. This critical essay analyzes the importance of expanding the debate, and the production of knowledge about the health of the black population (HBP), focusing on two points: the role of the National Policy for the Integral Health of the Black Population (PNSIPN) and the importance of including the skin color item in the health information systems; and the need for a process of permanent training of professionals, including contents related to the understanding of racism as an element of the social determination of health/disease and heir effects. To demonstrate how structural and institutional racism have affected the black population, we bring also examples of the quilombola populations in the context of the Covid-19 pandemic in the country since 2020. It is concluded that the promotion of care, the reduction of inequities and the quality of health care need to undergo changes in several dimensions, such as the strengthening of the SUS, the daily fight against structural and institutional racism, among others.

O racismo institucional impera nos serviços de saúde no Brasil, fundados em relações concretas de poder que subjugam, dominam e excluem negros/as do adequado acesso aos serviços e instituições de saúde. Este ensaio crítico analisa a importância da ampliação do debate e da produção do conhecimento sobre a saúde da população negra (SPN), focando dois pontos: o papel da Política Nacional de Saúde Integral da População Negra (PNSIPN) e a importância da inserção do quesito cor nos sistemas de informação em saúde; e a necessidade de um processo de formação permanente dos/as profissionais, inserindo conteúdos relacionados à compreensão do racismo como um dos elementos de determinação social de saúde/doença e seus efeitos. Para demonstrar como o racismo estrutural e institucional tem afetado a população negra, trazemos também exemplos das populações quilombolas no contexto da pandemia de COVID-19 no país a partir de 2020. Conclui-se que a promoção do cuidado, a redução das iniquidades e a qualidade da atenção à saúde precisam passar por mudanças em várias dimensões, como o fortalecimento do SUS e o combate cotidiano ao racismo estrutural e institucional.

Late Holocene dietary and cultural variability on the Xingu River, Amazon Basin: A stable isotopic approach.

Although once considered a 'counterfeit paradise', the Amazon Basin is now a region of increasing interest in discussions of pre-colonial tropical land-use and social complexity. Archaeobotany, archaeozoology, remote sensing and palaeoecology have revealed that, by the Late Holocene, populations in different parts of the Amazon Basin were using various domesticated plants, modifying soils, building earthworks, and even forming 'Garden Cities' along the Amazon River and its tributaries. However, there remains a relatively limited understanding as to how diets, environmental management, and social structures varied across this vast area. Here, we apply stable isotope analysis to human remains (n = 4 for collagen, n = 17 for tooth enamel), and associated fauna (n = 61 for collagen, n = 28 for tooth enamel), to directly determine the diets of populations living in the Volta Grande do Rio Xingu, an important region of pre-Columbian cultural interactions, between 390 cal. years BC and 1,675 cal. years AD. Our results highlight an ongoing dietary focus on C3 plants and wild terrestrial fauna and aquatic resources across sites and time periods, with varying integration of C4 plants (i.e. maize). We argue that, when compared to other datasets now available from elsewhere in the Amazon Basin, our study highlights the development of regional adaptations to local watercourses and forest types.

HTLV-1 and HTLV-2 Infection Among Warao Indigenous Refugees in the Brazilian Amazon: Challenges for Public Health in Times of Increasing Migration.

INTRODUCTION: Human T-lymphotropic virus (HTLV) infection is endemic in indigenous populations of the Americas. We describe herein the prevalence of HTLV-1 and HTLV-2 infection among Warao indigenous refugees from Venezuela living in Belém, Pará, Brazil. METHODS: In total, 101 individuals of both sexes (43 men and 58 women) between 18 and 77 years of age were investigated. Blood samples were collected and separated into plasma and leukocytes. Serological screening was performed using an enzyme-linked immunosorbent assay (ELISA; Murex HTLV-I+II, DiaSorin, Dartford, UK), and seropositive samples were submitted to proviral DNA extraction followed by real-time polymerase chain reaction (qPCR). A nested PCR of the env region (630 bp) followed by enzymatic digestion with XhoI was performed to identify the molecular subtype of HTLV-2, in addition to sequencing analysis of the 5'LTR-I and 5'-LTR-II regions. RESULTS: Of the 101 individuals analyzed, 3 (3.0%) were seropositive. Molecular analysis of the pol and tax genes confirmed the HTLV-1 infection in a 55-year-old woman and HTLV-2 infection in a man (68 years old) and a woman (23 years old). HTLV-2 strains were defined by enzymatic digestion as belonging to the HTLV-2b subtype. The sequencing of the 5'LTR regions confirmed the presence of subtype 2b and identified HTLV-1 as belonging to subtype 1A (Cosmopolitan) and the Transcontinental subgroup. Among the infected patients, it was possible to conduct medical interviews with two individuals after delivery of the result. One patient with HTLV-2 reported symptoms such as joint pain, foot swelling, frequent headache, dizziness and lower back pain. The HTLV-1-positive woman was diagnosed with a tumor, dementia, urinary incontinence, felt body pain, and had spots on her body. The presence of the HTLV-2b subtype highlights the prevalence of this molecular variant among indigenous South Americans, as well as the presence of HTLV-1 Transcontinental, which has a worldwide distribution. CONCLUSION: These results reveal a high prevalence of HTLV-1/2 infection among Warao immigrants, suggesting migratory flow as a virus spread mechanism among human populations and alert public authorities to the need to create epidemiological surveillance programs, public social and health policies aimed at welcoming immigrants in the Brazilian territory.

A 2-year observational study to determine the efficacy of a novel single incision sling procedure (Minitape) for female stress urinary incontinence.

OBJECTIVE: Assessment of the 2 year outcome of the Minitape procedure. DESIGN: A prospective observational study of women undergoing the Minitape procedure for urodynamic stress incontinence. Setting Two tertiary referral urogynaecology units in the north of England. POPULATION: Sixty women between November 2002 and March 2006. METHODS: Women attended a research clinic where they completed a standardised 1 hour pad test and were examined. Women were assessed preoperatively and postoperatively at 6 months, 1 year and 2 years. MAIN OUTCOME MEASURES: Success was determined by a negative 1 hour pad test (gain of <1 g) and no desire for further treatment for stress urinary incontinence. RESULTS: All procedures were completed with local anaesthesia, with no additional sedation in 82% of cases. Intra-operative and immediate postoperative complications were rare. Twelve women (20%) experienced mesh complications, half of which were considered to be serious adverse events requiring exit from the study. At 2 years following Minitape insertion, six women (10%) were defined as cured. CONCLUSIONS: Although feasible to perform, this procedure is associated with a substantially lower cure rate than that published previously for other procedures. Cure rates decline over the 2 year follow-up period, especially during the first 6 months.

Anthropometric measurements of adolescents from two Amazonian ecosystems: variations according to seasonality.

This paper aims to describe the nutritional status of Caboclo adolescents living in two areas of the Amazon Basin. Two cross-sectional studies, the first in the dry and the second in the wet season, were carried out in two Amazonian ecosystems: the forest and black water ecosystem, and the floodplain and white water ecosystem. Measurements of weight, stature, arm circumference and triceps, subscapular and suprailiac skinfolds were performed on 247 adolescents (10-19 years of age). Nutritional status was classified using body mass index according to international criteria and the prevalence of underweight and overweight was estimated. Linear mixed effects models were used with the anthropometric measurements as dependent variables and time interval, place of residence, sex, age and stature variation as independent variables. During the wet season, the prevalence of overweight among girls was higher in the forest (42%) than in the floodplain (9%). Longitudinal linear regression models showed that the arm circumference measurement was influenced both by seasonality and location, revealing that the increment between dry and wet seasons was less pronounced in the floodplain. At the time of the study, overweight already constituted a major public health concern among girls living in the forest area. In order to develop adequate public health policies for this important segment of the Amazon population further studies are necessary to investigate the role of environment and seasonality on the growth and nutritional status of adolescents.

Urethral injury associated with minimally invasive mid-urethral sling procedures for the treatment of stress urinary incontinence: a case series and systematic literature search.

The introduction of the TVT has brought about dramatic changes in our practice as regards surgery for stress urinary incontinence, although the risk of bladder injury has caused concern. The subsequent development of tapes introduced through the obturator foramina may limit the rate of bladder injury, and some have suggested that cystoscopy is no longer required during stress incontinence surgery. Several cases of urethral injury referred to our unit have caused us concern about this approach. We present here brief details of these cases along with a systematic search of the literature on urethral injury following mid-urethral tape procedures.

Tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence: 5-year follow up.

OBJECTIVE: To compare the long-term outcomes of tension-free vaginal tape (TVT) and colposuspension as primary treatment for stress incontinence. STUDY DESIGN: Multicentre randomised controlled trial. SETTING: Secondary and tertiary care gynaecology, urology and urogynaecology departments in 14 centres in the UK and Eire. POPULATION: Women with urodynamically confirmed stress incontinence and who had previously failed to respond to conservative treatment were invited to participate. METHODS: Three hundred and forty-four women were randomised; 175 to TVT and 169 to colposuspension. This paper reports the 5-year outcomes. MAIN OUTCOME MEASURES: The primary outcome at 5 years was a 1-hour perineal pad test; other outcomes included clinical examination, Short Form-36 (SF-36) health status and Bristol Female Lower Urinary Tract Symptoms (BFLUTS) questionnaires. RESULTS: A negative 1-hour pad test was recorded in 58/72 (81%) women in the TVT group and 44/49 (90%) in the colposuspension group (P = 0.21, Fisher's exact test) at 5 years. There was an increase in enterocoele and rectocele in the colposuspension group; three late tape complications were seen in the TVT group. CONCLUSION: This study did not detect a significant difference between TVT and colposuspension for the cure of stress incontinence at 5 years. The effect of both procedures on cure of incontinence and improvement in quality of life is maintained in the long term. Vault and posterior vaginal wall prolapse are seen more commonly after colposuspension. Tape erosion may occur several years after surgery.