Anterior mid-tibial stress fractures. Results of surgical treatment.

BACKGROUND AND AIMS: An anterior mid-tibial stress fracture is an uncommon, but possibly career threatening condition for an athlete. We wanted to evaluate the results of the surgical treatment of this notorious stress fracture and compare two different surgical methods. MATERIAL AND METHODS: Forty-nine anterior mid-tibial stress fractures were treated surgically in 45 patients during the years 1985-2005. All the patients were athletes, mainly runners. The mean age of the patients was 26 years. Thirty-four of the fractures occurred in men and 15 in women. The first method of treatment (anteromedial and lateral drilling) was used in 20 operations and the second method (laminofixation) in 29 operations. RESULTS: Good results were achieved with drilling in only 50 % of the operations, where as with laminofixation good results were achieved in 93 % of operations. This difference was statistically significant (p = .002). Healing of the stress fracture after laminofixation occurred in less than 6 months. The length of the plate used in the laminofixation had no effect on the end result. CONCLUSIONS: An anterior mid-tibial stress fracture may often lead to delayed union or non-union in vigorously training athletes. Surgical treatment with laminofixation proved to be superior to tibial fracture site drilling.

Lifetime use of psychiatric medications and cognition at 43years of age in schizophrenia in the Northern Finland Birth Cohort 1966.

BACKGROUND: Higher lifetime antipsychotic exposure has been associated with poorer cognition in schizophrenia. The cognitive effects of adjunctive psychiatric medications and lifetime trends of antipsychotic use remain largely unclear. We aimed to study how lifetime and current benzodiazepine and antidepressant medications, lifetime trends of antipsychotic use and antipsychotic polypharmacy are associated with cognitive performance in midlife schizophrenia. METHODS: Sixty participants with DSM-IV schizophrenia from the Northern Finland Birth Cohort 1966 were examined at 43years of age with an extensive cognitive test battery. Cumulative lifetime and current use of psychiatric medications were collected from medical records and interviews. The associations between medication and principal component analysis-based cognitive composite score were analysed using linear regression. RESULTS: Lifetime cumulative DDD years of benzodiazepine and antidepressant medications were not significantly associated with global cognition. Being without antipsychotic medication (for minimum 11months) before the cognitive examination was associated with better cognitive performance (P=0.007) and higher lifetime cumulative DDD years of antipsychotics with poorer cognition (P=0.020), when adjusted for gender, onset age and lifetime hospital treatment days. Other lifetime trends of antipsychotic use, such as a long antipsychotic-free period earlier in the treatment history, and antipsychotic polypharmacy, were not significantly associated with cognition. CONCLUSIONS: Based on these naturalistic data, low exposure to adjunctive benzodiazepine and antidepressant medications does not seem to affect cognition nor explain the possible negative effects of high dose long-term antipsychotic medication on cognition in schizophrenia.

Regulation of the glycosylations of collagen hydroxylysine in chick embryo tendon and cartilage cells.

The regulation of the glycosylations of hydroxylysine was studied in isolated chick-embryo cells by labelling with a [14C]lysine pulse. The course of the procollagen lysyl modifications was compared in tendon and cartilage cells, and the effect on the gycosylations of the degree of lysyl hydroxylation and the concentration of Mn2+ and Fe2+ were also studied, in tendon cells. Procollagen triple helix formation was inhibited in most experiments in order to eliminate the effect of this process on the continuation of the reactions. Both in the tendon and cartilage cells the intracellular lysyl modifications proceeded in a biphasic fashion. After an initial sharp linear increase, the reactions did not cease but were protracted at a slower but constant rate. Lysyl hydroxylation was followed by rapid galactosylation in both cell types and this was followed almost immediately by rapid glucosylation, suggesting a close association of the corresponding enzymes. The data further suggest that other factors must also exist, in addition to the differences in the timing of triple helix formation and the actual hydroxylysine content, which are responsible for the different amounts of galactose in the collagens synthesized by these cell types. The amount of glucosylgalactosylhydroxylysine nevertheless seemed to be determined by the available acceptor sites, i.e., the amount of galactosylhydroxylysine. In further experiments with tendon cells the oxygen participating in lysyl hydroxylation was displaced by nitrogen at various points in time. When the degree of lysyl hydroxylation was reduced to less than one-third of the original, the total amounts of glycosylated residues decreased correspondingly, but their proportion relative to total hydroxylysine remained unchanged. Extra Mn2+ increased the proportion of galactosylated hydroxylysine, suggesting that the activity of hydrosylysyl galactosyltransferase is not saturating in respect of the catalyzed reaction. Experiments on the addition of Fe2+ or its chelation by alpha, alpha'-dipyridyl gave indications that the presence of this co-factor is not required for either glycosylation reaction in isolated tendon cells.

Comparison of costs between laparoscopic and open Nissen fundoplication: a prospective randomized study with a 3-month followup.

BACKGROUND: Laparoscopic antireflux surgery has replaced conventional operation despite the fact that currently no randomized trials have been published regarding its cost effectiveness. The objective of the present study was to compare costs and some short-term outcomes of laparoscopic and open Nissen fundoplication. STUDY DESIGN: Forty-two patients with documented gastroesophageal reflux disease were randomized between October 1995 and October 1996 to either laparoscopic (LNF) or open (ONF) Nissen fundoplication. Some short-term outcomes, Gastrointestinal Quality of Life Index (GIQLI) hospital costs, and costs to society were assessed. Followup was 3 months. RESULTS: Medians of operation times in the LNF and ONF groups were 98 min and 74 min, respectively. Hospital stay was 2.5 days shorter after laparoscopic operation (LNF 3 days versus ONF 5.5 days). Both operations were equally safe and effective, but the LNF group experienced significantly less pain and fatigue during the first 3 postoperative weeks. Improvement in the GIQLI and overall patient satisfaction were comparable between the methods. Convalescence was faster in the LNF group: return to normal life being 14 versus 31 days and return to work being 21 versus 44 days in the LNF and ONF groups, respectively. Hospital costs were similar, $2,981 and $3,140 in the LNF and ONF groups, respectively, but total costs were lower ($7,506 versus $13,118) in the LNF group as a result of an earlier return to work. CONCLUSIONS: LNF is superior in cost effectiveness, assuming that the longterm results between the methods are comparable.

Stress fracture of the medial malleolus.

We studied eight patients who had a stress fracture of the medial malleolus. The main symptom was localized pain on the medial side of the ankle. The initial radiographs revealed the lesion for only three patients; for the other patients, the diagnosis was made with the use of isotope scans and was confirmed with computerized tomography scans, magnetic resonance images, or subsequent plain radiographs. One vertical fracture was treated initially with compression with AO screws. On the basis of our experience with stress fractures in other bones, drilling was performed to enhance the formation of bone in two patients who had delayed healing and who had had symptoms for eight and twelve months. The fractures healed four and five months after the drilling. The five patients who were managed non-operatively had to avoid running and jumping for at least three months (average, four months) so that healing could take place. All five of these fractures healed within five months.

Comparison of laparoscopic and open Nissen fundoplication 2 years after operation. A prospective randomized trial.

BACKGROUND: Laparoscopic operation has replaced the conventional open procedure in the treatment of gastroesophageal reflux disease (GERD) in spite of the fact that long-term results based on controlled clinical trials have been lacking. The objective of this study was to compare outcome, quality of life, and patient satisfaction after laparoscopic and open Nissen fundoplication in a community hospital setting with a 2-year follow-up. METHODS: Forty-two patients with GERD were randomized to either laparoscopic (LNF) or open (ONF) Nissen fundoplication. Outcome evaluation included reflux symptoms, gastrointestinal quality of life (GIQLI), and upper GI endoscopy. RESULTS: Esophagitis was cured among all patients in the LNF group and in 90% of the ONF group. There were two patients (10%) in both groups who had medicine-dependent recurrent reflux together with significant worsening in the GIQLI scores. One patient in the LNF group has been reoperated due to a suture granuloma in the left epigastric port. Two patients in the LNF group needed esophageal dilatation due to persistent dysphagia. GIQLI scores (scale, 0-144) were equally normalized in both groups. Overall, 90% in the LNF and 100% in the ONF group were either satisfied or very satisfied with the operation. There was only one patient (LNF) who would not choose to have the operation again. CONCLUSIONS: Laparoscopic and open Nissen fundoplication seem to be equally effective methods for improving reflux symptoms and quality of life, resulting in a high rate of satisfaction among patients with an intermediate follow-up period of 2 years.

Five-year outcome of laparoscopic and Lichtenstein hernioplasties.

BACKGROUND: Laparoscopic hernia repair has been proved superior to open repairs in terms of short-term results, but long-term results of laparoscopic and open mesh repairs have been lacking until recently. METHODS: A total of 123 patients were randomly allocated to two treatment groups comparing laparoscopic and Lichtenstein hernioplasties in three separate trials. The first and second trials compared small and large mesh used in transabdominal preperitoneal repairs, and the third study compared totally extraperitoneal hernioplasty with the Lichtenstein operation. A 5-year follow-up visit was scheduled to assess recurrencies, symptoms, and patient satisfaction. RESULTS: For the follow up evaluation, 121 (98.4%) of the patients were reached. There were five hernia recurrences in the laparoscopic group (small mesh) and two in the Lichtenstein group (difference, 5%; 95% confidence interval, -4-13%; p = 0.3). One patient who underwent the transabdominal preperitoneal polypropylene procedure underwent reoperation 3 years later because of dense small bowel adhesions at the inguinal surgical site. Chronic groin pain was more common after open operation (0 vs 4) patients (difference 7%; confidence interval, -0.4-16%; p = 0.04). Ten patients (16%) in the laparoscopic group and 12 (20%) in the open group reported discomfort or pain at the surgical site. CONCLUSIONS: Both laparoscopic and Lichtenstein hernioplasties have a low risk for hernia recurrence if proper mesh size is used. The patients who undergo hernioplasty with open mesh hernioplasty seem to experience chronic symptoms and pain more often than those managed with the laparoscopic procedure.

Delayed unions and nonunions of stress fractures in athletes.

From 1971 to 1985, 369 athletes presented to us with stress fractures. Of these patients, 10% (37) were treated for development of delayed unions or nonunions. Twenty-seven of the patients were male and 10 were female. Their mean age was 23.1 years (range, 17 to 39). About half of the athletes were involved in endurance sports. The diagnostic criteria for a delayed union or nonunion were clinical and radiological evidence. There was a diagnostic delay of about 3.5 months in the series. Plain radiographs, tomography, and isotope scans were used in the diagnosis. Special radiographic views were also used. In 15 cases (10 hallux sesamoid bone fractures, 1 midtibial shaft fracture, 1 metatarsal V base fracture, 1 tarsal navicular fracture, 1 olecranon fracture, and 1 proximal tibial shaft fracture) nonoperative treatment was used. Operative treatment was used 22 times (5 sesamoid fractures, 5 midtibial fractures, 5 metatarsal V base fractures, 3 tarsal navicular fractures, 3 olecranon fractures, and 1 proximal tibial shaft fracture). Results were good or excellent in 32 cases (86.5%), moderate in 4 cases, and poor in 1 case.

Stress avulsion fracture of the tarsal navicular. An uncommon sports-related overuse injury.

We report nine cases of stress-related avulsion fracture of the tarsal navicular in athletes. This uncommon over-use injury is thought to occur following repetitive cyclic compressive loading secondary to an impingement of the tarsal navicular. The small dorsal triangular fragment is best seen in weightbearing lateral view radiographs and isotope scan and/or tomography help confirm the diagnosis. We feel that operative treatment is the method of choice in highly symptomatic cases and among top athletes because of the shorter recovery time.

Risk factors for recurrent stress fractures in athletes.

Our aim was to identify factors predisposing athletes to multiple stress fractures, with the emphasis on biomechanical factors. Our hypothesis was that certain anatomic factors of the ankle are associated with risk of multiple stress fractures of the lower extremities in athletes. Thirty-one athletes (19 men and 12 women) with at least three separate stress fractures each, and a control group of 15 athletes without fractures completed a questionnaire focusing on putative risk factors for stress fractures, such as nutrition, training history, and hormonal history in women. Bone mineral density was measured by dual-energy x-ray absorptiometry in the lumbar spine and proximal femur. Biomechanical features such as foot structure, pronation and supination of the ankle, dorsiflexion of the ankle, forefoot varus and valgus, leg-length inequality, range of hip rotation, simple and choice reaction times, and balance in standing were measured. There was an average of 3.7 (range, 3 to 6) fractures in each athlete, totaling 114 fractures. The fracture site was the tibia or fibula in 70% of the fractures in men and the foot and ankle in 50% of the fractures in women. Most of the patients were runners (61%); the mean weekly running mileage was 117 km. Biomechanical factors associated with multiple stress fractures were high longitudinal arch of the foot, leg-length inequality, and excessive forefoot varus. Nearly half of the female patients (40%) reported menstrual irregularities. Runners with high weekly training mileage were found to be at risk of recurrent stress fractures of the lower extremities.

Diagnosis and treatment of delayed and non-union stress fractures in athletes.

Stress fractures in athletes usually heal well with merely rest and conservative treatment. It has been estimated that in Finland 400-500 athletic stress fractures occur annually per year. In sports clinic series stress fractures comprise 3.3 to 4.6 per cent of all overuse injuries. Delayed and non-union have been reported to occur in athletes quite often, up to 10 per cent of athletic stress fractures in Finland. The reason is on the one hand delayed diagnosis due to late consultation of expert physicians, and on the other hand too short a rest from hard physical activity. Delayed and non-union are most often seen in the hallux sesamoids, mid-tibial staft, base of fifth metatarsal, tarsal navicular and olecranon. The pars articularis of the fourth and fifth lumbar vertebra is a site of stress fracture and spondylolysis. In this report the diagnosis, symptoms and findings as well as the operative treatment of these overuse injuries is discussed.

Stress fractures in athletes.

During the 14-year period of 1971-1985, 368 stress fractures in 324 athletes were treated. The series contained 268 fractures in males and 100 fractures in females; 32 fractures occurred in children (less than 16 years), 117 in adolescents (16-19 years), and 219 in adults. Forty-six fractures were incurred by athletes at an international level, 274 by athletes at a national or district level and 48 by recreational athletes. Of the total cases, 72% occurred to runners and a further 12% to athletes in other sports after running exercises. The distribution of the stress fractures by site was: tibia 182, metatarsal bones 73, fibula 44, big toe sesamoid bones 15, femoral shaft 14, femoral neck 9, tarsal navicular 9, pelvis 7, olecranon 5 and other bones 10. Of the total fractures, 342 were treated conservatively and 26 fractures required surgical treatment. The operative indication was dislocation in 5 cases and delayed union/nonunion in 21 cases. The sites most often affected by delayed union were: anterior midtibia, sesamoid bones of the big toe, base of the fifth metatarsal, olecranon, and tarsal navicular. The athletes at an international level experienced the greatest risk of multiple separate fractures, protracted healing, or fractures requiring surgery.

Stress fracture of the mid-tibial shaft.

In a series of 151 tibial stress fractures in athletes and joggers, seven were located at the mid-third of the diaphysis. The diagnosis was made radiographically several months after the onset of symptoms; a transverse fissure line or gap was noted in the middle of the hypertrophied anterior tibial cortex. Histologic examination of a biopsy of the fracture line showed features resembling pseudoarthrosis. All the patients returned to physical activities.

Stress fractures of the olecranon in javelin throwers.

Between the years 1977 and 1984, four javelin throwers with a stress fracture of the olecranon were seen and treated. In one patient, acute painful dislocation of the fracture occurred during a competitive throw. Two patients had stress fracture of the tip. The fracture treated conservatively healed in 18 months. The patient treated by excision of the tip was able to throw after 2 months. Two patients had slightly oblique, more distally located stress fractures, which were treated with a tension band and 2 Kirschner wires. The fractures healed in 4 months. One of the patients had a refracture 11 months after the primary operation. It was successfully treated with a compression screw and two bone pegs. Because of the high risk of delayed union and nonunion, stress fractures of the olecranon should be treated operatively in javelin throwers.

Stress fractures in young athletes.

In a series of 16 cases of stress fractures in 15-year-old and younger athletes 8 fractures occurred in boys and 8 in girls. There were no differences between the sexes in the athletes' training habits. Ten of the fractures were located at the tibia, seven at its upper third and three at the lower part of the bone. Three fractures were found in the fibula, in the metatarsal bones two stress fractures and in the femur one stress fracture. Most stress fractures were caused by endurance type sports. The daily training distances were not particularly high at the time of the onset of the symptoms. In most cases the diagnosis was based on a radiological evaluation. A sufficiently long pause from all athletic activity was enough treatment. Stress fractures in children are very uncommon.