Lateral and Posterior Approaches in Hemiarthroplasty.

PURPOSE: Hemiarthroplasty is a common treatment for patient with a fragility displaced femoral neck fracture. We compared lateral and posterior approaches with respect to need for mobility aids, mobility level, living arrangements, pain, hip dislocation, and survival 12 months after hip fracture. METHODS: A total of 393 fragility femoral neck fracture patients aged 65 years or more who underwent hemiarthroplasty were observed for 12 months. Patient information was collected on admission, during hospitalization, and by telephone interview 1 year after the hip fracture. A total of 269 patients were included in the final analysis. RESULTS: At 1 year after hip fracture, more patients undergoing hemiarthroplasty with the posterior approach (22%) survived without mobility aids compared to those with the lateral approach (12%; p = 0.026). Multivariate logistic regression analysis revealed that the need for mobility aids 1 year after hip fracture was significantly predicted by the use of mobility aids before the fracture (odds ratio = 13.46, 95% confidence interval = 4.29-42.25), age ≥85 years (odds ratio = 3.85, 95% confidence interval = 1.09-13.44), male sex (odds ratio = 3.59, 95% confidence interval = 1.05-12.22), and lateral approach (odds ratio 2.73, 95% confidence interval 1.15-6.50). The posterior approach resulted in four (3.4%) dislocated hips, compared with none by the lateral approach. Survival, mobility level, pain in the operated hip, and living arrangements 1 year postoperatively were not significantly different between groups. CONCLUSION: Hemiarthroplasty using a lateral approach predisposed to the need for ambulatory aids 1 year after hip fracture. The posterior approach, however, predisposed to hip dislocation. Patient selection must be considered when deciding the appropriate surgical approach.

Knee injuries related to sports in young adult males during military service - incidence and risk factors.

The population-based incidence and risk factors for knee injuries in young adults were assessed in Finnish male conscripts performing their compulsory military service (n = 128,584). The main outcome variables were (1) hospitalization due to knee injuries overall and (2) hospitalization due to knee disorders as categorized into specific International Classification of Diseases, tenth revision diagnoses (cruciate and collateral ligament tears, meniscal tears, traumatic chondral lesions, and patellar dislocations). Person-time injury-incidence rates were calculated by dividing the number of persons with a diagnosed knee injury by the total exposure time of 97,503 person-years. The number of subjects with surgical operations and military service class changes indicative of longer term notable disability are also reported. Risk factor analyses were performed by logistic regression. The person-based incidence of hospitalizations for knee injury was 11 cases per 1000 person-years [95% confidence interval (CI): 10.4-11.7]. The most important risk factors were higher age (odds ratio 1.7; 95% CI: 1.3-2.2) and obesity (odds ratio 1.6; 95% CI: 1.03-2.5). Two thirds of all subjects hospitalized for knee injuries had surgery, and one third had longer term notable disability. These findings indicate that knee injuries cause a significant burden of hospitalizations, often leading to surgery and longer term disability.

Sensitivity of MRI for articular cartilage lesions of the patellae.

BACKGROUND AND AIMS: Reliable diagnosis of articular cartilage lesions of the patellae is often based on arthroscopy. However, unnecessary arthroscopies should be avoided. The aim of this study was to assess the sensitivity and applicability of MRI to diagnosing articular cartilage lesions of the patellae. MATERIALS AND METHODS: We identified 74 consecutive males (mean age 21 years, range 18-28) from the medical records of our institute with the sole diagnosis of articular cartilage lesions of the patellae based on arthroscopy. Magnetic resonance imaging was performed with 1.0 Tesla scanner a mean of 4 weeks before arthroscopy. Sensitivity of symptoms, and MRI for the diagnosis was calculated. RESULTS: Based on arthroscopy, 20 (27%) cases of cartilage lesions of the patellae were grade-I, 32 (43%) were grade-II, and 22 (30%) were grade-III. MRI revealed cartilage lesions of the patellae in 49 knees (66%), indicating that the sensitivity of MRI was 66% (95% CI: 53%-74%). MRI sensitivity increased with the severity of chondral lesions: all grade III to IV lesions were detected (sensitivity 100%, 95% CI: 85%-100%) by MRI. Grade of articular cartilage lesions of the patellae based on arthroscopy was not associated with clinical symptoms (p=0.61). CONCLUSIONS: The sensitivity of 1.0 Tesla MRI for detecting grade-I lesions was low and could not be used to confirm the diagnosis of articular cartilage lesions of the patellae. For the detection of more severe grade-II to III lesions, the MRI sensitivity was markedly higher. MRI may thus be considered an accurate diagnostic tool for identifying more severe cases of articular cartilage lesions of the patellae.

Can orthotic insoles prevent lower limb overuse injuries? A randomized-controlled trial of 228 subjects.

Lower limb overuse injuries are common among people who are exposed to physical stress. Orthotic shoe insoles are widely used to prevent lower limb overuse injuries. Here, we conducted a randomized-controlled study to examine whether the use of orthotic insoles prevents lower limb overuse injuries. Participants (n=228) were randomly assigned to use (n=73) or not to use (n=147) orthotic insoles. The insoles were molded to the shape of the foot to provide support during physical activity. The main outcome measure in the present study was the physician-diagnosed lower limb overuse injury. Thirty-four (46.6%) subjects in the insole group were diagnosed with a lower limb overuse injury compared with 56 (38.1%) in the control group (P=0.29) during the 6-month study period. When body mass index and the results of a 12-min running test and muscle strength were adjusted in a Cox's regression model, the hazard ratio for lower limb overuse injury in the insole group was 1.3 (95% confidence intervals: 0.8-2.1) compared with the control group. Use of orthotic insoles was not associated with a decrease in lower limb overuse injuries. Our findings suggest that routine use of orthotic insoles does not prevent physical-stress-related lower limb injuries in healthy young male adults.

Anabolic-androgenic steroid use among young Finnish males.

The aim of the present study was to describe the lifetime occurrence and associated factors of anabolic-androgenic steroids (AAS) among young Finnish males. Of the 10 829 male conscripts (median age 19), 10 396 (96%) answered a questionnaire during the first days of their conscription in the years 2001-2007. The main outcome was lifetime AAS use. We also studied associations between 13 socioeconomic, health, and health behavioral background variables and AAS use by logistic regression. Eighty-nine (0.9%) respondents reported having used AAS. In addition, 26 (0.3%) respondents reported that they would use AAS if they could obtain them. In multivariate analysis, which included all significant variables and age, the strongest associated factors were weight training at fitness centers more than three times a week [odds ratio (OR) 11.8; 95% confidence interval (CI): 7.1-19.6], low educational status (OR 3.7; 95% CI: 2.0-7.0), and weekly drunkenness as drinking style (OR 2.4; 95% CI: 1.4-4.5). Sports other than weight training were not associated with AAS in our sample. The use of AAS is relatively uncommon among Finnish males. It is strongly associated with weight training at fitness centers but also with lower educational status and a drunkenness-oriented lifestyle. Prevention should be targeted at those males participating in weight training.

Cervical hip fracture in a Finnish population: incidence and mortality.

BACKGROUND AND AIMS: Our aim was to describe the incidence of cervical hip fractures and to describe the relationships between selected background variables and mortality at 30 days, 6 months, and 3 years postoperatively. MATERIAL AND METHODS: The basic material consisted of population-based data set of patients aged 65 years or older who had sustained a hip fracture and were treated operatively between 1999 and 2000. Out of these, we identified 266 consecutive patients with cervical hip fracture. RESULTS: The age-adjusted incidence of cervical hip fractures in women was 1.3-fold compared to men. In age-adjusted analysis, occurrence of chronic lung disease, cardiovascular disease or 2-5 comorbidities, male gender, the need for 2-person mobility assistance, and poor ambulation postoperatively were associated with excess mortality at least at one evaluation point. CONCLUSIONS: Only chronic lung disease and male gender were independent predictors of increased mortality at each follow-up assessment in multivariate analysis.

DEXA body composition changes among 140 conscripts.

The aim of the study was to determine changes in body composition and physical fitness during military service. A prospective cohort study of 140 healthy male conscripts was conducted. We examined subject characteristics, aerobic performance and muscle strength, and assessed body composition using dual-energy X-ray absorptiometry (DEXA) three times. Conscripts' mean baseline weight (79.5 kg) decreased by 2 kg during the first 3 months, but increased by 0.9 kg during the second 3-month period (p<0.001). Fat mass measured by DEXA decreased by 3.2 kg during the first but increased by 0.8 kg during the second 3-month period (p<0.001). Throughout the 6-month study, an increase was seen in distance of 12-min run test (from 2 380 m to 2 530 m; p<0.001), and muscle strength score (from 6.5 to 9.5 p<0.001). Finnish military training seems to have beneficial effects on physical fitness. However, considering the relatively modest changes in body fat and physical fitness seen in conscripts with average BMIs at baseline, design of diverse training programmes for the varying baseline BMI levels are warranted to improve the physical fitness results.

Can elevated serum TRACP-5b levels predict stress fractures? A cohort study.

BACKGROUND AND AIMS: Stress fracture is a common overuse injury in athletes and military conscripts. The reliable diagnosis of stress fractures is often difficult, however, because it is usually based solely on radiographic findings. Biochemical markers of bone resorption reflect bone degradation and may also reflect the rate of bone loss. The aim of the study was to examine whether elevated serum tartrate-resistant acid phosphatase isoform 5b (TRACP-5b) levels reflect enhanced bone remodeling and predict the occurrence of stress fractures in military conscripts. MATERIAL AND METHODS: Randomly selected military conscripts [mean age, 19.8 (range 18-28) years; n = 820] were followed for 3 months. Baseline blood samples were drawn upon arrival to the service. Four subsequent samples were obtained from subjects that developed stress fractures and one sample each was obtained from two asymptomatic control subjects for each fracture case. RESULTS: Plain radiography was used to diagnose stress fractures in 20 of the 820 conscripts (2.4%). Follow-up data were available for 14 subjects with 21 stress fractures and 28 control subjects. Subjects with proportionally increasing serum TRACP-5b levels had an 8-fold greater probability of stress fracture than controls. No statistically significant difference was detected. CONCLUSIONS: Although assessing serum TRACP-5b levels appears to be a promising method to predict bone stress injuries, the present study failed to give a conclusive statement of its usefulness as a diagnostic tool.

Long-term outcome of a transglenoid suture technique for anterior shoulder instability in young adults.

We reviewed the outcome of arthroscopic stabilisation of anterior glenohumeral instability in young adults using the transglenoid suture technique. A questionnaire was sent to 455 consecutive patients who had undergone this procedure between 1992 and 2000. Of these, 312 patients (68.5%) with 313 affected shoulders and a mean age of 20 years (18 to 28) responded. Outcome was determined by the number of re-dislocations or, in patients who had not re-dislocated, by the disease-specific quality of life as measured by the Western Ontario Shoulder Instability index. During a mean follow-up of 6.4 years (1 to 14), 177 patients (56%) sustained a re-dislocation, including 70 who required a further operation. In 136 patients (44%) who reported neither re-dislocation nor re-operation, the index scores were good (median 90.4%; 28.9% to 100%). No significant peri- or pre-operative predictors of re-dislocation or re-operation were found. We found a high rate of re-dislocation after transglenoid suture repair in young, physically active patients.

An association between socioeconomic, health and health behavioural indicators and fractures in young adult males.

UNLABELLED: The aim of this survey study with 7,083 male respondents was to examine the association between socioeconomic, health and health behavioural risk indicators and fractures. In the multivariate regression model, fractures were associated strongest with frequency of drunkenness, regular sports training, frequent use of health care services and obesity. INTRODUCTION: Little is known about the risk factors for fractures in young adults. Our aim was to identify the association between socioeconomic background, health and health behaviours and fractures. METHODS: The survey sample comprised 7,378 conscript males (median age 19), of which 7,083 (96%) answered. The outcome was self-reported fracture. Associations between 20 background variables and fractures were analysed with logistic regression. RESULTS: Altogether 2,456 (34.7%) participants reported fracture(s) during their lifetime. The most common anatomical locations of fracture were the forearm, the hand and the ankle. The strongest risk indicators for fractures were frequent drunkenness (OR 1.7; 95% CI: 1.3-2.0), regular sports training (OR 1.6; 95% CI: 1.3-1.9), frequent use of health care services (OR 1.5; 95% CI: 1.3-1.8) and obesity (OR 1.5; 95% CI: 1.2-1.9). CONCLUSIONS: This is among the first studies to describe risk indicators for fractures in young adults. The strongest risk factors for fractures were associated with health damaging behaviour, high-intensity physical activity and use of health care services. Of socioeconomic background factors, only living in the capital city area was associated with fractures. Preventive measures should be targeted at the males frequently using health care services or actively participating in sports.

Elongated patellae at the final stage of Osgood-Schlatter disease: a radiographic study.

Aetiology of Osgood-Schlatter disease (OSD) is still unknown. Relative length of the patellar articular surface with the length of the patella, relative height of the tibial tubercle with the sagittal diameter of the tibia, Insall-Salvati, Blackburne-Peel, and Caton-Deschamps indexes, as well as Grelsamer-morphology type of the patella were measured from preoperative plain X-rays in 82 knees of 20-year-old males with OSD and in 87 knees of 20-year-old male controls with normal MRI findings of the knee. Seventy-eight of the OSD patients had separate ossicles. Their mean patellar morphology index was 1.44 and that of the controls was 1.28 (p<0.001), indicating significant lengthening of the patellar body among the OSD group. OSD patients had also significantly more often Grelsamer type II (elongated patellae) than the controls. Tibial tuberosity was significantly higher among OSD patients, but was not correlated with the lengthening of the patella. An increased patellar height among OSD patients was shown by the Blackburne-Peel and Caton-Deschamps indexes (p<0.001) and the Insall-Salvati index (p=0.018). OSD patients exhibit elongated patellae and patellar tendons which may result from long-standing tension of the extensor apparatus during growth spurt, when femoral growth exceeds that of the anterior structures of the knee.

Long-term outcome of undisplaced fatigue fractures of the femoral neck in young male adults.

The incidence and long-term outcome of undisplaced fatigue fractures of the femoral neck treated conservatively were examined in Finnish military conscripts between 1970 and 1990. From 106 cases identified, 66 patients with 70 fractures were followed for a mean of 18.3 years (11 to 32). The original medical records and radiographs were studied and physical and radiological follow-up data analysed for evidence of risk factors for this injury. The development of avascular necrosis and osteoarthritis was determined from the follow-up radiographs and MR scans. The impact of new military instructions on the management of hip-related pain was assessed following their introduction in 1986. The preventive regimen (1986) improved awareness and increased the detected incidence from 13.2 per 100,000 service-years (1970 to 1986) to 53.2 per 100,000 (1987 to 1990). No patient developed displacement of the fracture or avascular necrosis of the femoral head, or suffered from adverse complications. No differences were found in MRI-measured hip joint spaces at final follow-up. The mean Harris Hip Score was 97 (70 to 100) and the Visual Analogue Scale 5.85 mm (0 to 44). Non-operative treatment, including avoidance of or reduced weight-bearing, gave favourable short- and long-term outcomes. Undisplaced fatigue fractures of the femoral neck neither predispose to avascular necrosis nor the subsequent development of osteoarthritis of the hip.

Fatal explosion injuries in Finland: a twenty-year nationwide survey.

BACKGROUND AND AIMS: Expanding violence may necessitate treatment of explosion victims, requiring a broadening of existing medical skills and knowlegde of injury mechanisms. The aim of the study was to assess the number, nature and injury pattern of fatal explosion incidents in Finland. MATERIAL AND METHODS: Retrospective analysis of explosion-related deaths from January 1985 to December 2004. Death certificates were obtained and reviewed. RESULTS: Over the 20-year period from 1985 to 2004, only 61 inviduals died in Finland as a result of unintentional or unspecified explosion related events. A homemade bomb assault for unknown motives killed seven people in a suburb in 2002. The incidence was 5.7 cases per 10,000,000 person-years. Suicides using explosives were slightly more common; on average 4 cases per year (6.7 cases per 10,000,000 person-years). A small increase in the fatality trend was noticeable during the last years of the study period. CONCLUSIONS: The incidence of fatal explosion injuries is a minor problem, but a small increase can be seen during the last few years. Victims of such injuries required only minimal hospital resources, because in most cases they died at the scene. Our results suggest that efforts to prevent fatalities related to explosives or corresponding devices, or to reduce their number, should focus on prevention of intentions.

Severe vascular gunshot injuries of the extremities: a ten-year nation-wide analysis from Finland.

BACKGROUND AND AIMS: Gunshot wounds affecting the main vessels of the extremities mostly threaten limb salvage. The purpose of this study was to analyse the nature and severity of civilian vascular gunshot injuries of the extremities using a nation-wide database. MATERIAL AND METHODS: Retrospective analysis of the Finnish Hospital Discharge Register, hospital records and death certificates over a 10-year period from January 1, 1990 to December 31, 1999. RESULTS: Thirty-two individuals with the mean age of 33 years (17-68) sustained 43 severe vascular injuries to the extremities caused by gunshots. The incidence was 6.0 (95% CI: 4.1-8.5) per 10,000,000 person-years and did not change significantly during the period. Four of the injured died. The most common anatomical locations of vascular injuries were the femoral artery (6 lesions), popliteal artery (6) and superficial femoral artery (5). Use of alcohol was detected in ten cases (32% of patients) and of illegal drugs in seven cases (22%). Five patients (18% of non-fatal injuries) required vascular re-operation caused by post-operative problems. Five amputations were performed as primary treatment. CONCLUSIONS: Severe vascular gunshot injuries of the extremities are not common in Finland. The need for primary amputation or vascular re-operations is noteworthy.

Vitamin D fortification as public health policy: significant improvement in vitamin D status in young Finnish men.

BACKGROUND: Vitamin D insufficiency is common in northern countries during wintertime. In Finland, after the recommendation by the Ministry of Social Affairs and Health, vitamin D has been added to liquid milk products and margarines from February 2003. OBJECTIVE: We determined the effects of national policy on vitamin D fortification on vitamin D status among young Finnish men. DESIGN: A comparison before and after intervention with study population of 196 young Finnish men (18-28 years) was carried out. Serum 25-hydroxyvitamin D3 (25-OHD3) concentrations were determined with the OCTEIA enzymeimmunoassay by IDS (Immunodiagnostic Systems Limited, Bolden, UK) in January 2003 (n = 96) and in January 2004 (n = 100), nearly 1 year after national vitamin D fortification had started. RESULTS: The mean serum 25-OHD3 concentrations during the wintertime increased by 50% after implementation of the vitamin D fortification of dairy products. Correspondingly, the prevalence of vitamin D insufficiency (serum 25-OHD3 < 40 nmol/l) was decreased by 50% from 78% in January 2003 to 35% in January 2004. CONCLUSIONS: Our results demonstrate that national vitamin D fortification substantially improved the vitamin D status of young Finnish men. Still, a third remained vitamin D insufficient.

Tissue restoration after resorption of polyglycolide and poly-laevo-lactic acid screws.

Despite worldwide clinical use of bio-absorbable devices for internal fixation in orthopaedic surgery, the degradation behaviour and tissue replacement of these implants are not fully understood. In a long-term experimental study, we have determined the patterns of tissue restoration 36 and 54 months after implantation of polyglycolic acid and poly-laevo-lactic acid screws in the distal femur of the rabbit. After 36 months in the polyglycolic acid group the specimens showed no remaining polymer and loose connective tissue occupied 80% of the screw track. Tissue restoration remained poor at 54 months, the amounts of trabecular bone and haematopoietic elements being significantly lower than those in the intact control group. The amount of trabecular bone within the screw track at 54 months in the polyglycolic acid group was less than in the empty drill holes (p = 0.04). In the poly-laevo-lactic acid group, polymeric material was present in abundance after 54 months, occupying 60% of the cross-section of the core area of the screw track. When using absorbable internal fixation implants we should recognise that the degradation of the devices will probably not be accompanied by the restoration of normal trabecular bone.

Fatigue injuries of the femur.

The purpose of this study was to describe the anatomical distribution and incidence of fatigue injuries of the femur in physically-active young adults, based upon MRI studies. During a period of 70 months, 1857 patients with exercise-induced pain in the femur underwent MRI of the pelvis, hips, femora, and/or knees. Of these, 170 patients had a total of 185 fatigue injuries, giving an incidence of 199 per 100 000 person-years. Bilateral injuries occurred in 9% of patients. The three most common sites affected were the femoral neck (50%), the condylar area (24%) and the proximal shaft (18%). A fatigue reaction was seen in 57%, and a fracture line in 22%. There was a statistical correlation between the severity of the fatigue injury and the duration of pain (p = 0.001). The location of the pain was normally at the site of the fatigue injury. Fatigue injuries of the femur appear to be relatively common in physically-active patients.

Bone stress injuries.

Bone stress injuries are due to cyclical overuse of the bone. They are relatively common in athletes and military recruits but also among otherwise healthy people who have recently started new or intensive physical activity. Diagnosis of bone stress injuries is based on the patient's history of increased physical activity and on imaging findings. The general symptom of a bone stress injury is stress-related pain. Bone stress injuries are difficult to diagnose based only on a clinical examination because the clinical symptoms may vary depending on the phase of the pathophysiological spectrum in the bone stress injury. Imaging studies are needed to ensure an early and exact diagnosis, because if the diagnosis is not delayed most bone stress injuries heal well without complications.

MR imaging, bone scintigraphy, and radiography in bone stress injuries of the pelvis and the lower extremity.

PURPOSE: To compare MR imaging, radiography and bone scintigraphy in the diagnosis of stress injuries to bones of the pelvis and lower extremity. MATERIAL AND METHODS: Fifty consecutive conscripts with clinical signs of a stress injury to bone underwent MR imaging and bone scintigraphy. Forty-three patients also had radiographs available. Bone scintigraphy served as a gold standard. RESULTS: Compared to the bone scintigraphy, the sensitivity of radiography was 56%, specificity 94%, accuracy 67%, positive predictive value (PPV) 95%, and negative predictive value (NPV) 48%. The kappa value for radiography and bone scintigraphy was fair (0.39). Correspondingly, the sensitivity of MR imaging was 100%, specificity 86%, accuracy 95%, PPV 93% and NPV 100%. The kappa value for MR imaging and bone scintigraphy was very good (0.89). MR imaging depicted 3 bone stress injuries that were not visible on bone scintigraphy. Positive findings obtained from radiography correlated with MR signs of fracture line or callus (p<0.001). CONCLUSION: MR imaging is more sensitive than two-phase bone scintigraphy, and MR imaging should be used as the gold standard in the assessment of stress injuries of bone. Radiography reveals mainly the late phases of bone stress injuries, such as stress fracture and callus.

Fatal firearm injuries in Finland: a nationwide survey.

BACKGROUND AND AIMS: Treatment of life-threatening firearm injuries represents major challenges to the involved medical staff. The aim of the study was to assess numbers, natures and injury patterns of fatal incidents by firearms in Finland over a 10-year period. MATERIAL AND METHODS: Retrospective analysis of all firearm-related deaths during the 10-year period from January 1990 to December 1999. Death certificates were obtained and reviewed with detailed analysis of non-suicidal deaths. RESULTS: Over the 10-year period 1990 to 1999, 452 individuals (equivalent to 1.8 cases per 100 000 person-years) died in Finland as a result of accidental or violent shooting. There were no significant changes in numbers of cases from year to year. The male-female ratio was 7:3. The mean age of the victims was 32 years. The shooting incident had been classified as an assault in 78% of cases. Its nature was unspecified in 13% of cases and clearly accidental in 9%. The predominant anatomical site of fatal injury following assault was the chest in 43%, the head in 42% and the abdomen in 8% of the cases. After accidental or unspecified nature shooting, the predominant site of injury was the head in 68%, followed by the chest in 16% and the abdomen in 10% of the cases. Most victims (86%) died at the scene of the shooting. Only 14% were alive at hospital admittance. Most hospitalised victims died within 24 hours of admission. CONCLUSIONS: The annual incidence of fatal non-suicidal firearm injuries did not change significantly in Finland between 1990 and 1999. Victims of such injuries required only minimal hospital resources because in most cases they died at the scene of the shooting. The results of the study reported indicate that efforts to prevent fatal injuries from use of firearms or diminish their number should be focused mainly on prevention of firearm related assault.