Five-Year Follow-Up of Surgery vs Functional Bracing for Closed Displaced Humeral Shaft Fractures.

This study compares outcomes of surgery and functional bracing for closed humeral shaft fractures after 5 years of follow-up.

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.

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.

Outcomes With Surgery vs Functional Bracing for Patients With Closed, Displaced Humeral Shaft Fractures and the Need for Secondary Surgery: A Prespecified Secondary Analysis of the FISH Randomized Clinical Trial.

IMPORTANCE: Existing evidence indicates that surgery fails to provide superior functional outcome over nonoperative care in patients with a closed humeral shaft fracture. However, up to one-third of patients treated nonoperatively may require secondary surgery. OBJECTIVE: To compare the 2-year outcomes of patients who required secondary surgery with the outcomes of patients with successful initial treatment. DESIGN, SETTING, AND PARTICIPANTS: This 2-year follow-up of the Finnish Shaft of the Humerus (FISH) randomized clinical trial comparing surgery with nonoperative treatment (functional brace) was completed in January 2020. Enrollment in the original trial was between November 2012 and January 2018 at 2 university hospital trauma centers in Finland. A total of 321 adult patients with closed, displaced humeral shaft fracture were assessed for eligibility. After excluding patients with cognitive disabilities, multimorbidity, or multiple trauma and those refusing randomization, 82 patients were randomized. INTERVENTIONS: Interventions were surgery with plate fixation (n = 38; initial surgery group) or functional bracing (n = 44); the latter group was divided into the successful fracture healing group (n = 30; bracing group) and the secondary surgery group (n = 14) with fracture healing problems. MAIN OUTCOMES AND MEASURES: The primary outcome was Disabilities of Arm, Shoulder and Hand (DASH) score at 2 years (range, 0 to 100 points; 0 denotes no disability, 100 extreme disability; minimal clinically important difference, 10 points). RESULTS: Of 82 randomized patients, 38 (46%) were female. The mean (SD) age was 48.9 (17.1) years. A total of 74 patients (90%) completed the 2-year follow-up. At 2 years, the mean DASH score was 6.8 (95% CI, 2.3 to 11.4) in the initial surgery group, 6.0 (95% CI, 1.0 to 11.0) in the bracing group, and 17.5 (95% CI, 10.5 to 24.5) in the secondary surgery group. The between-group difference was -10.7 points (95% CI, -19.1 to -2.3; P = .01) between the initial and secondary surgery groups and -11.5 points (95% CI, -20.1 to -2.9; P = .009) between the bracing group and secondary surgery group. CONCLUSIONS AND RELEVANCE: Patients contemplating treatment for closed humeral shaft fracture should be informed that two-thirds of patients treated with functional bracing may heal successfully while one-third may experience fracture healing problems that require secondary surgery and lead to inferior functional outcomes 2 years after the injury. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01719887.

Distal Biceps Tendon Rupture Surgery: Changing Incidence in Finnish and Swedish Men Between 1997 and 2016.

PURPOSE: Distal biceps tendon rupture is a relatively rare injury usually occurring with excess external extension force applied to a flexed elbow. The aim of this study was to examine the incidence of distal biceps tendon rupture surgery in the Finnish and Swedish adult population between the years 1997 and 2016. A secondary aim was to investigate the distal biceps rupture incidence in the Swedish population in 2001 to 2016. METHODS: We assessed the number and rate of distal biceps tendon rupture surgery using the Finnish and Swedish Hospital Discharge Register as databases. The study included the entire Finnish and Swedish adult population aged 18 years and older between January 1, 1997 and of December 31, 2016. RESULTS: During the study period, 2,029 patients had a distal biceps tendon rupture in Finland, and the corresponding figure was 2,000 in Sweden. The rate of distal biceps tendon rupture surgery increased steeply, but equally, in both countries, in Finnish men from 1.3 per 100,000 person-years in 1997 to 9.6 in 2016, and in Swedish men from 0.2 in 1997 to 5.6 in 2016. The incidence of distal biceps tendon rupture in Sweden increased in men from 1.6 to 10.0 per 100,000 person-years from 2001 to 2016. CONCLUSIONS: There was a 7-fold and a 28-fold increase in the incidence of distal biceps tendon rupture surgery in Finnish and Swedish men during 1997 to 2016. The incidence of distal biceps tendon rupture rose 6-fold in Swedish men in 2001 to 2016. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Trends of shoulder instability surgery in Finland: a nationwide register study.

OBJECTIVE: Rate of shoulder instability surgery (SIS) has increased in different specific populations. We analysed nationwide trend of SIS in adults in Finland between 1997 and 2014. DESIGN: A retrospective register study. SETTING: National Hospital Discharge Register of Finland. PARTICIPANTS: A total of 22 550 adult patients with SIS in Finland (1997-2014). PRIMARY AND SECONDARY OUTCOME MEASURES: Analysis included appropriate diagnosis (International Classification of Diseases 10) and procedure coding combinations applicable for SIS. The primary outcome variable was the incidence of SIS per 100 000 person-years, and the secondary outcomes were the study year, sex, age groups (18-29, 30-49 and over 50 years of age) and the type of hospital (public or private). RESULTS: The overall nationwide rate of SIS in adults increased 177% between 1997 and 2014 in Finland. The rate was the lowest (13/100 000 person-years) in 1997, and the peak rate (40/100 000 person-years) was noted in 2007. The increase in rate was rapid between 1997 and 2007, after which the rate became stable. During the study period, the highest increases were noted in the young adults age group (270%), and especially in the middle-aged group who were operated on in private hospitals (930%). CONCLUSIONS: The rate of SIS increased almost threefold in Finland from 1997 to 2014. The increase was most significant in young and middle-aged adults (18-50 years), in men, and in private hospitals.

Effect of Surgery vs Functional Bracing on Functional Outcome Among Patients With Closed Displaced Humeral Shaft Fractures: The FISH Randomized Clinical Trial.

Importance: Humeral shaft fractures traditionally have been treated nonsurgically, but there has been a steady increase in the rate of surgery over the past 2 decades without high-quality evidence to justify the trend. Objective: To compare the effectiveness of surgical treatment with open reduction and internal plate fixation to nonsurgical treatment with functional bracing in the treatment of closed humeral shaft fractures. Design, Setting, and Participants: Randomized clinical trial conducted at 2 university hospital trauma centers in Finland, enrollment between November 2012 and January 2018 with a final follow-up of January 2019. A total of 82 adult patients with closed, unilateral, displaced humeral shaft fracture met criteria for inclusion. Patients were excluded if they had cognitive disabilities preventing them from following the protocol or had multimorbidity or multiple trauma. Interventions: Patients were randomly assigned to surgical treatment with open reduction and internal plate fixation (n = 38) or to nonsurgical treatment with functional bracing (n = 44). Main Outcome and Measure: The primary outcome was Disabilities of Arm, Shoulder and Hand (DASH) score at 12 months (range, 0 to 100 points, 0 denotes no disability and 100 extreme disability; minimal clinically important difference, 10 points). Results: Among 82 patients who were randomized (mean age, 48.9 years; 38 women [46%]; 44 men [54%]), 78 (95%) completed the trial. Thirteen (30%) of the patients assigned to functional bracing underwent surgery during the 12-month follow-up period to promote healing of the fracture. At 12 months, the mean DASH score was 8.9 (95% CI, 4.2 to 13.6) in the surgery group and 12.0 (95% CI, 7.7 to 16.4) in the bracing group (between-group difference, -3.1 points; 95% CI, -9.6 to 3.3; P = .34). Eleven patients (25%) allocated to functional bracing developed fracture nonunion. Three patients (8%) allocated to surgery developed a temporary radial nerve palsy. Conclusions and Relevance: Among patients with closed humeral shaft fracture, internal fixation surgery, compared with nonoperative functional bracing, did not significantly improve functional outcomes at 12 months. However, the substantial amount of treatment crossover from nonoperative to surgical treatment should be considered when interpreting the trial results. Trial Registration: ClinicalTrials.gov Identifier: NCT01719887.

Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial.

BACKGROUND: Although increasingly used, the benefit of surgical treatment of displaced 2-part proximal humerus fractures has not been proven. This trial evaluates the clinical effectiveness of surgery with locking plate compared with non-operative treatment for these fractures. METHODS AND FINDINGS: The NITEP group conducted a superiority, assessor-blinded, multicenter randomized trial in 6 hospitals in Finland, Estonia, Sweden, and Denmark. Eighty-eight patients aged 60 years or older with displaced (more than 1 cm or 45 degrees) 2-part surgical or anatomical neck proximal humerus fracture were randomly assigned in a 1:1 ratio to undergo either operative treatment with a locking plate or non-operative treatment. The mean age of patients was 72 years in the non-operative group and 73 years in the operative group, with a female sex distribution of 95% and 87%, respectively. Patients were recruited between February 2011 and April 2016. The primary outcome measure was Disabilities of Arm, Shoulder, and Hand (DASH) score at 2-year follow-up. Secondary outcomes included Constant-Murley score, the visual analogue scale for pain, the quality of life questionnaire 15D, EuroQol Group's 5-dimension self-reported questionnaire EQ-5D, the Oxford Shoulder Score, and complications. The mean DASH score (0 best, 100 worst) at 2 years was 18.5 points for the operative treatment group and 17.4 points for the non-operative group (mean difference 1.1 [95% CI -7.8 to 9.4], p = 0.81). At 2 years, there were no statistically or clinically significant between-group differences in any of the outcome measures. All 3 complications resulting in secondary surgery occurred in the operative group. The lack of blinding in patient-reported outcome assessment is a limitation of the study. Our assessor physiotherapists were, however, blinded. CONCLUSIONS: This trial found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus. These results suggest that the current practice of performing surgery on the majority of displaced proximal 2-part fractures of the humerus in older adults may not be beneficial. TRIAL REGISTRATION: ClinicalTrials.gov NCT01246167.

Intraobserver and interobserver reliability of recategorized Neer classification in differentiating 2-part surgical neck fractures from multi-fragmented proximal humeral fractures in 116 patients.

BACKGROUND: Optimal fracture classification should be simple and reproducible and should guide treatment. For proximal humeral fractures, the Neer classification is commonly used. However, intraobserver and interobserver reliability of the Neer classification has been shown to be poor. In clinical practice, it is essential to differentiate 2-part surgical neck fractures from multi-fragmented fractures. Thus, the aim of this study was to evaluate whether surgeons can differentiate 2-part surgical neck fractures from multi-fragmented fractures using plain radiographs and/or computed tomography (CT). METHODS: Three experienced upper limb specialists and trauma surgeons (B.O.S., A.P.L., and V.L.) independently reviewed and classified blinded plain radiographs and CT scans of 116 patients as showing 2-part surgical neck fractures or multi-fragmented fractures. Each imaging modality was reviewed and classified separately by each surgeon, after which each surgeon reviewed both modalities at the same time. This process was repeated by all surgeons after 24 weeks. Intraobserver and interobserver analyses were conducted using Cohen and Fleiss κ values, respectively. RESULTS: The κ coefficient for interobserver reliability showed substantial correlation (0.61-0.73) and was as follows: 0.73 for radiographs alone, 0.61 for CT scans alone, and 0.72 for radiographs and CT scans viewed together. After 24 weeks, the process was repeated and intraobserver reliability was calculated.The κ coefficient for intraobserver reliability showed substantial correlation (0.62-0.75) and was as follows: 0.62 for radiographs alone, 0.64 for CT scans alone, and 0.75 for radiographs and CT scans viewed together. CONCLUSION: Clinicians were able to differentiate 2-part surgical neck fractures from multi-fragmented fractures based on plain radiographs reliably.

Treatment of proximal humerus fractures in the elderly.

A proximal humerus fracture typically occurs when an elderly woman falls directly onto her shoulder or on her outstretched arm. Local pain in the shoulder and immobility of the upper arm raise a suspicion of a significant injury. Other bone and tendon injuries in the shoulder region as well as dislocation of the shoulder should be considered on differential diagnosis. Diagnosis is achieved by plain X-ray. Most fractures can be treated conservatively. Consultation with an orthopedist is needed, if there are several fracture fragments with extensive dislocation.

Open reduction and internal fixation of humeral shaft fractures versus conservative treatment with a functional brace: a study protocol of a randomised controlled trial embedded in a cohort.

INTRODUCTION: Humeral shaft fractures represent 1%-3% of all fractures and 20% of humeral fractures in adults. The treatment of these fractures is mainly conservative and operative treatment is usually reserved for specific circumstances. To date, no randomised controlled trial (RCT) has compared operative treatment of humeral shaft fractures with conservative treatment. METHODS AND ANALYSIS: We will conduct an RCT to compare the effectiveness and cost-effectiveness of surgical and conservative treatment of humeral shaft fractures. After providing informed consent, 80 patients from 18 years of age with humeral shaft fracture will be randomly assigned to open reduction and internal fixation with locking plate or conservative treatment with functional bracing. We will follow the patients for 10 years and compare the results at different time points. The primary outcome will be Disabilities of Arm, Shoulder and Hand (DASH) at 12 months. The secondary outcomes will include Numerical Rating Scale for pain at rest and in activities, Constant Score and quality of life instrument 15D. Patients not willing to participate in the RCT will be asked to participate in a prospective cohort follow-up study, 'the declined cohort'. This cohort will be followed up at the same time points as the randomised patients to assess the potential effect of participation bias on RCT results and to enhance the external validity of the RCT. In one of the recruiting centres, all cooperative patients with humeral shaft fractures not eligible for randomisation will be asked to participate in a 'non-eligible cohort' study. We will use blinded data interpretation of the randomised cohort to avoid biased interpretation of outcomes. Our null hypothesis is that there is no clinically relevant difference in the primary outcome measure between the two treatment groups. We will consider a difference of a minimum of 10 points in DASH clinically relevant. ETHICS AND DISSEMINATION: The institutional review board of the Helsinki and Uusimaa Hospital District has approved the protocol. We will disseminate the findings of this study through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT01719887; pre-results.

Trends in the Incidence of Clavicle Fractures and Surgical Repair in Sweden: 2001-2012.

BACKGROUND: Clavicle fractures are common injuries causing substantial morbidity. Recent literature suggests that the incidence of surgically treated clavicle fractures has increased. However, it is unknown whether the increase is caused by more surgeons choosing operative over nonoperative treatment for the injury or an increase in the actual incidence of clavicle fractures. The aim of this study was to assess both the national incidence of clavicle fractures and the rate of surgical treatment of those fractures in Sweden. METHODS: We assessed the incidence and trends of clavicle fractures and rates of surgery in Sweden. The validated Swedish Hospital Discharge Register offers a unique opportunity to assess both outpatient and inpatient visits and was used to conduct a national register-based study including all adults (≥18 years of age) with a diagnosis of clavicle fracture in Sweden between 2001 and 2012. RESULTS: A total of 44,609 clavicle fractures occurred in Sweden between 2001 and 2012. The incidence of clavicle fractures increased from 35.6 per 100,000 person-years in 2001 to 59.3 per 100,000 person-years in 2012. Interestingly, the highest incidence rates were observed in the oldest age groups. The increase in the rate of surgically treated clavicle fractures (705%) was greater than the increase in the actual fracture incidence (67%). Most (77%) of the surgically treated patients were men. Open reduction and plate fixation was the most common surgical procedure. Overall, the proportion of surgically treated clavicle fractures increased markedly. CONCLUSIONS: Although the incidence of clavicle fractures increased in Sweden between 2001 and 2012, the rate of surgical treatment of clavicle fractures increased much more than could be expected solely based on the increase in the fracture incidence. The observed changes in the rates of surgery require additional studies since there is still controversy regarding the indications for surgical treatment.

Increasing incidence of rotator cuff repairs--A nationwide registry study in Finland.

BACKGROUND: Rotator cuff repair incidence rates have reportedly increased in the United States and England. Here we analyzed nationwide data relating to rotator cuff repairs recorded in the Finnish National Hospital Discharge Register (NHDR). METHODS: The NHDR was reviewed to identify adult patients who underwent rotator cuff repair between 1998 and 2011. Incidence rates per 10(5) person-years were calculated using the annual adult population size. RESULTS: During the 14-year time period, 50,646 rotator cuff repairs were performed on subjects aged 18 years or older. The incidence of rotator cuff repair showed an almost linear increase of 204%, from 44 per 10(5) person-years in 1998 to 131 per 10(5) person-years in 2011. The most common concomitant procedure was acromioplasty, which was performed in approximately 40% of rotator cuff repairs in 2011. Other common concomitant procedures included tenodesis (7%) and tenotomy (6%) of the long head of the biceps tendon, and resection of the acromioclavicular joint (3%). CONCLUSIONS: This nationwide analysis revealed a remarkable increase in the incidence of rotator cuff repair from 1998 to 2011 in Finland. This progress can be questioned, since there are not convincing data of the superiority of the operative treatment over non-operative management in all rotator cuff tears.

[Update on current care guidelines. The tendon disorders of the shoulder]. / Kaypa Hoite-Suosituksen Paivitystiivistelma. Olkapään jännevaivat.

Degenerative rotator cuff tendon disease (tendinopathy) is the most common disorder of the shoulder. A full-thickness tear of the rotator cuff may be caused by degeneration, or it may develop due to an acute trauma. The typical symptoms include pain and functional deficiencies. Diagnostics is based on clinical findings. The primary radiologic imaging is x-ray. Degenerative tendon diseases are primarily treated conservatively in primary health care, the most important treatment modality is physiotherapy-guided therapeutic rehabilitation. Surgical treatment is considered in full-thickness rotator cuff tears, especially after traumatic onset.

Epidemiology of proximal humerus fractures.

UNLABELLED: There are only a few previous population-based studies that include both inpatient and outpatient treatment data. The aim of this study was to investigate the epidemiology of proximal humerus fractures. The incidence of proximal humerus fractures increases with age, and we observe a seasonal variation strongly favoring winter months. PURPOSE: Proximal humerus fractures are the third most common osteoporotic fracture type observed in elderly patients, after wrist and hip fractures. However, few previous population-based studies include both inpatient and outpatient treatment data. The aim of this study was to investigate the incidence, fracture morphology, and treatment method provided in cases of proximal humerus fractures. METHODS: We retrospectively studied patient records from a mid-sized town in Finland between the years 2006 and 2010. The following data were collected from the medical records: age, sex, date of the fracture, laterality of the fracture, mechanism of injury, treatment method, and other associated fractures at the time of the original injury. Sex and age distributions of the patient population at risk (>18 years old) were calculated for the study period. RESULTS: A total of 678 patients (females n = 503, 73 %) with 692 proximal humerus fractures were identified. The unadjusted incidence was 82 (95 % CI 76 to 88) per 100,000 person-years, 114 (95 % CI 104 to 124), and 47 (95 % CI 41 to 54) per 100,000 person-years in females and males, respectively. Incidence increased toward the older age groups. Clear seasonal variation was observed, two-part fractures were most common (428, 62 %), the majority of the fractures (n = 539, 78 %) were treated nonoperatively with a sling. CONCLUSION: The incidence of proximal humerus fractures increases with age, and we observe a seasonal variation strongly favoring winter months. It is evident that proximal humerus fractures cause considerable morbidity among elderly people and consume health care resources.

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.

Declining incidence of acromioplasty in Finland.

BACKGROUND AND PURPOSE: An increased incidence rate of acromioplasty has been reported; we analyzed data from the Finnish National Hospital Discharge Register. PATIENTS AND METHODS: During the 14-year study period (1998-2011), 68,877 acromioplasties without rotator cuff repair were performed on subjects aged 18 years or older. RESULTS: The incidence of acromioplasty increased by 117% from 75 to 163 per 10(5) person years between 1998 and 2007. The highest incidence was observed in 2007, after which the incidence rate decreased by 20% to 131 per 10(5) person years in 2011. The incidence declined even more at non-profit public hospitals from 2007 to 2011. In contrast, it continued to rise at profit-based private orthopedic clinics. INTERPRETATION: We propose that this change in clinical practice is due to accumulating high-quality scientific evidence that shows no difference in outcome between acromioplasty and non-surgical interventions for rotator cuff disease with subacromial impingement syndrome. However, the exact cause of the declining incidence cannot be defined based solely on a registry study. Interestingly, this change was not observed at private clinics, where the number of operations increased steadily from 2007 to 2011.

Surgical treatment of clavicular fractures in Finland - A register based study between 1987 and 2010.

BACKGROUND: Clavicle fractures are among the most common upper extremity injuries. Traditionally most clavicle fractures have been treated non-surgically, but during recent decades the surgical treatment of clavicle fractures has increased. The purpose of this study was to assess the numbers and trends of surgically treated clavicle fractures in Finland between 1987 and 2010. METHODS: The study covered the entire adult (>18 years) population of Finland over the study period. Data on surgically treated clavicle fractures was collected from the Finnish National Hospital Discharge Register. We assessed the number and incidence of surgically treated clavicle fractures annually. RESULTS: A total of 7073 surgically treated clavicle fractures were identified in the register over the study period. Three-fourths of the surgically treated patients were men and one-fourth was women. The incidence of surgical treatment increased nearly ninefold from 1.3 per 100,000 person years in 1987 to 10.8 per 100,000 person years in 2010. The increase in the rate of surgical treatment was especially notable in men. CONCLUSIONS: A striking increase in incidence of surgically treated clavicle fractures was seen from 1987 to 2010. Although the actual incidence of clavicle fractures is not known, we assume that the proportion of patients receiving surgical treatment has increased markedly without high-quality evidence. Since recent reports have suggested similar functional results between operative and conservative treatment critical evaluation of the treatment policy of clavicle fractures is warranted.

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.

Surgical treatment of humeral-shaft fractures: a register-based study in Finland between 1987 and 2009.

INTRODUCTION: Humeral-shaft fractures are not uncommon osteoporotic fractures. While most of the humeral-shaft fractures can be treated conservatively, some need surgical treatment. The purpose of this study was to assess the trends of the surgical treatment of humeral-shaft fractures. The study determined whether surgical treatment of humeral-shaft fractures has changed in Finland between 1987 and 2009. We assessed the number and incidence of surgically treated humeral-shaft fractures in each year and recorded the type of surgery used. PATIENTS AND METHODS: The study covered the entire adult (>18 years) population in Finland over the 23-year period from 1 January 1987 to 31 December 2009. Data on surgically treated humeral-shaft fractures were obtained from the nationwide National Hospital Discharge Registry. RESULTS: During the 23-year study period, a total of 4469 surgical operations of the humeral shaft were performed in Finland. The male patients were markedly younger (49 years) than their female counterparts (63 years). The incidence of surgical treatment nearly doubled in men and over tripled in women. Between 1987 and 2009, there occurred a clear shift towards plating in the surgical treatment of humeral-shaft fractures. CONCLUSIONS: A marked increase in the surgical treatment of humeral-shaft fractures was seen in Finland in 1987-2009. Fracture plating increased during the first decade of the millennium. Since high-quality evidence for treatment of humeral-shaft fractures is absent, critical evaluation of the chosen treatment options is needed.