A Comprehensive Approach to PROMs in Elective Orthopedic Surgery: Comparing Effect Sizes across Patient Subgroups.

Background: There is limited knowledge regarding the comparative patient-reported outcomes (PROMs) and effect sizes (ESs) across orthopedic elective surgery. Methods: All patient data between January 2020 and December 2022 were collected, and treatment outcomes assessed as a PROM difference between baseline and one-year follow-up. The cohort was divided into subgroups (hand, elbow, shoulder, spine, hip, knee, and foot/ankle). The PROM ESs were calculated for each patient separately, and patients with ES > 0.5 were considered responders. Results: In total, 7695 patients were operated on. The mean ES across all patient groups was 1.81 (SD 1.41), and the largest ES was observed in shoulder patients and the smallest in hand patients. Overall, shoulder, hip, and knee patients had a larger ES compared to hand, spine, and foot/ankle patients (p < 0.0001). The proportion of positive responders ranged between 91-94% in the knee, shoulder, and hip, and 69-70% in the hand, spine, and foot/ankle subgroups. Conclusions: The ESs are generally high throughout elective orthopedic surgery. However, based on our institutional observations, shoulder, hip, and knee patients experience larger treatment effects compared to hand, spine, and foot/ankle patients, among whom there are also more non-responders. The expected treatment outcomes should be clearly communicated to patients when considering elective surgery. Because of the study limitations, the results should be approached with some caution.

Mortality and subsequent fractures of patients with olecranon fractures compared to other upper extremity osteoporotic fractures.

Background: The incidence rate of olecranon fractures is highest in the elderly population. The aim of this study was to determine whether patients with olecranon fractures have similar demographic and risk characteristics compared to patients with osteoporotic upper extremity fractures. Methods: A retrospective data analysis was performed with diagnoses for olecranon fracture, distal radius fracture and proximal humerus fracture between 2014 and 2016. Results: A total of 157 olecranon, 1022 distal radius and 451 proximal humerus fractures were identified. The risk of mortality after olecranon and distal radius fractures was comparable but statistically significantly higher after proximal humerus fractures (HR 1.97, 95% CI 1.19-3.27). The risk of subsequent osteoporotic fractures after an olecranon fracture was 10% at 1 year and 14% at 5 years and the risks did not differ statistically after a proximal humerus fracture, 6% and 11% (HR 0.65, 95% CI 0.40-1.06). After a distal radius fracture, the risks were statistically significantly lower: 2% and 5% (HR 0.35, 95% CI 0.22-0.56). Discussion: Patients with olecranon fractures have essentially similar demographic characteristics compared to patients with distal radius fractures, but the probability for a subsequent fracture is significantly higher and more comparable to patients with proximal humerus fractures.

Experience with Tissue Bank Services in 2014 and 2020 in Turku, Finland.

BACKGROUND: The objective of a musculoskeletal tissue bank is to collect, test, store, and provide musculoskeletal tissue allografts required in orthopedic procedures. Strict exclusion criteria are followed when selecting suitable cadaver musculoskeletal tissue donors, and the allografts are procured under sterile conditions to avoid bacterial contamination. Tissue banking in Turku, Finland, began in 1972, and tissue bank services were last reviewed in 2003. This study aimed to review the operation of the musculoskeletal tissue bank in Turku, Finland, between 2014 and 2020 and to analyze the number, types, and contamination rate of the allografts procured from the cadaver donors. Potential donor-related factors causing bacterial contamination of the allografts and whether potential musculoskeletal tissue donors were overlooked among multiorgan donors were also studied. METHODS: A retrospective review of all cadaver musculoskeletal tissue donors used in the Hospital District of Southwest Finland Tyks Orto Musculoskeletal Tissue Bank during the study period was conducted, and data on the procured allograft was collected and presented. The donors were selected among patients treated in the intensive care unit (ICU) of Turku University Hospital (TYKS). RESULTS: A total of 28 cadaver donors were used, and 636 allografts were procured between 2014 and 2020. The bacterial contamination rate was 2.5%, which was lower than that in the previous international literature. The median treatment time in the ICU was significantly longer, and the median value of the highest C-reactive protein level was significantly higher in the group of donors with positive allograft bacterial cultures. CONCLUSIONS: The bacterial contamination rate in the tissue bank was low on an international scale. Some suitable musculoskeletal tissue donors were overlooked among multiorgan donors.

Increased lesion depth, higher body mass index and older age are risk factors for osteoarthritis during long-term follow-up in patients with osteochondritis dissecans of the knee.

INTRODUCTION: To report on the long-term prognosis of osteochondritis dissecans (OCD) patients regarding radiological and patient-reported outcomes and to analyze possible risk factors. MATERIALS AND METHODS: All patients diagnosed with knee OCD between 2004 and 2014 with radiographic Kellgren-Lawrence (K-L) grades 0-2 at the time of diagnoses, ability to understand the language of the interview, and willingness to participate in the study were retrospectively reviewed. Current knee radiographs and the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire were prospectively collected between May 2020 and March 2021. The extent of osteoarthritis (OA) and KOOS questionnaire results were evaluated. RESULTS: 90 patients (103 knees) with a mean age of 21 years (range 6-60) were included. The mean follow-up time was 12 years (range 7-20). 24 knees (23%) were treated conservatively, and 79 knees (77%) operatively. At the time of diagnoses, 90% of the patients had K-L grades of 0-1; during the follow-up period, 45% of the patients showed radiological progression of OA. Patient body mass index (BMI) (p = 0.004; 95% CI 0.25-0.29), age (p = 0.003; 95% CI 0.18-0.30), operative treatment (p = 0.0075; 95% CI 0.41-0.65) and lesion depth (p = 0.0007) were statistically significantly connected to K-L grade change. Patients with no progression in joint space narrowing had statistically significantly better overall KOOS scores (p = 0.03; 95% CI 0.77-0.88) than patients whose K-L grades worsened. CONCLUSIONS: During the long-term follow-up of 12 years, patients with knee OCD had good clinical results. Lac of radiological progression of cartilage degeneration was noted in 55% of the patients, regardless of treatment method. Lesion depth, higher BMI and older age were associated with the progression of OA. The progression of OA was related to a worsening of functional scores. LEVEL OF EVIDENCE: IV.

Incidence and Treatment Trends of Achilles Tendon Ruptures in Finland: A Nationwide Study.

Background: Global reports indicate rising Achilles tendon rupture (ATR) incidence. In recent decades, the optimal treatment for this injury has been widely studied. Alongside the cumulating comparative evidence regarding the optimal method of treatment, nonoperative treatment has increased in popularity compared with operative treatment. Purpose: To determine the current incidence of ATRs and their treatment in Finland and how these have changed from 1997 to 2019. Study Design: Descriptive epidemiology study. Methods: Two national registers (the National Hospital Discharge Register and the Finnish Register of Primary Health Care Visits) were used to identify all ATR cases and operations to treat them; the incidence was calculated based on the annual adult population size. Results: During the study period, ATR incidence increased from 17.3 to 32.3 per 100,000 person-years. The increase in incidence seemed to plateau starting in the second half of the study period. The rise in ATR incidence occurred in both sexes and all age groups but most markedly among the elderly. The incidence of operative treatment decreased from 13.6 to 4.9 per 100,000 person-years. This decline was observed from 2008 onward and in all age groups. Conclusion: The incidence of ATRs increased and the use of operative treatment decreased. The decreasing trend of operative treatment is in line with other international reports and resonates with the current literature about the optimal treatment of ATRs.

Changes in operative treatment of tibia fractures in Finland between 2000 and 2018: A nationwide study.

INTRODUCTION: Incidences of different tibia fractures are not well reported. Possible changes in the operative treatment methods have also not been studied. The aim of this nationwide registry study is to determine the incidence of operatively treated tibia fractures and investigate the possible changes in treatment methods in Finland between 2000 and 2018. METHODS: All patients aged 16 years or older with operatively treated tibia fractures in Finland from 2000 to 2018 were included. The incidence of operatively treated proximal, diaphyseal, and distal tibia fractures per 100,000 person years by age, sex, mechanism of injury, and study year was calculated. Data were extracted from the Finnish National Hospital Discharge Register. RESULTS: A total of 5996 proximal, 6874 diaphyseal, and 5658 distal tibia fractures were reported during the 18-year study period, resulting in incidences of 7.2/100,000, 8.1/100,000, and 6.9/100,000 person years for operatively treated proximal, diaphyseal, and distal tibia fractures, respectively. Over the study period, a clear change in fixation method in distal tibia fractures was found as plating became popular in the beginning of the 21st century. During the last 5 years of the study period, nailing and plating were equally used. CONCLUSIONS: Operatively treated proximal tibia fractures are most common among older females while diaphyseal fractures are most frequent in young male patients. Distal tibia fractures occur most often among middle-aged people.

Proximal humeral fractures in Finland : trends in the incidence and methods of treatment between 1997 and 2019.

AIMS: Proximal humeral fractures (PHFs) are common. There is increasing evidence that most of these fractures should be treated conservatively. However, recent studies have shown an increase in use of operative treatment. The aim of this study was to identify the trends in the incidence and methods of treatment of PHFs in Finland. METHODS: The study included all Finnish inhabitants aged ≥ 16 years between 1997 and 2019. All records, including diagnostic codes for PHFs and all surgical procedure codes for these fractures, were identified from two national registers. Data exclusion criteria were implemented in order to identify only acute PHFs, and the operations performed to treat them. RESULTS: During the 23-year study period, 79,676 PHFs were identified, and 14,941 operations were performed to treat them. The incidence of PHFs steadily increased. In 2019, the overall incidence was 105 per 100,000 person-years (105). The sex-adjusted incidence for females was 147.1 per 105, and the age-adjusted incidence for patients aged ≥ 80 years was 407.1 per 105. The incidence of operative treatment for PHFs rose during the first half of the study period and decreased during the second half. The use of plate osteosynthesis in particular decreased. In 2019, the incidence of operative treatment for PHFs was 13.2 per 105, with 604 operations. CONCLUSION: Although the incidence of PHFs is steadily increasing, particularly in elderly females, the incidence of operative treatment is now decreasing, which is in line with current literature regarding their treatment. Cite this article: Bone Joint J 2022;104-B(1):150-156.

Preoperative Posterior Tilt Increases the Risk of Later Conversion to Arthroplasty After Osteosynthesis for Femoral Neck Fracture.

BACKGROUND: Femoral neck fractures (FNFs) are one of the most common injuries in the elderly. Treatment is either internal fixation or primary arthroplasty. The main aim of this study is to assess the risk factors associated with fixation failure leading to further arthroplasty in FNFs treated with cannulated screws. METHODS: Data on internal fixations of FNFs performed at Turku University Hospital between January 1, 2012 and December 31, 2017 were collected retrospectively from the patient database. Radiographical measurements were performed for preoperative displacement and posterior tilt, postoperative displacement, reduction quality, and implant shaft angle. RESULTS: Altogether 301 cases were included in the study. The overall reoperation rate was 25% and conversion to arthroplasty was performed in 16% of cases. In the multiple variant analysis, adjusted for age and gender, nondisplaced fractures with a 0°-20° preoperative posterior tilt had a significantly lower risk of later conversion to arthroplasty than did nondisplaced fractures with a ≤0° or ≥20° posterior tilt (odds ratio [OR] 4.0, 95% confidence interval [Cl] 1.8-8.6, P = .0005) and displaced fractures (OR 7.2, 95% CI 3.0-17.4, P < .0001). No statistically significant association was found between preoperatively nondisplaced fractures with a <0° or ≥20° posterior tilt and displaced fractures (OR 0.6, 95% Cl 0.2-1.3, P = .2). CONCLUSION: Displaced fractures and fractures with a preoperative posterior tilt of <0° or ≥20° have a considerably increased risk of reoperation and conversion to arthroplasty. Primary arthroplasty should be considered as treatment for displaced FNFs and fractures with >20° or <0° posterior tilt, especially in fragile patients, to avoid further operations.

Posterior approach, fracture diagnosis, and american society of anesthesiology class iii-iv are associated with increased risk of revision for dislocation after total hip arthroplasty: An analysis of 33,337 operations from the finnish arthroplasty register.

BACKGROUND AND OBJECTIVE: Dislocation is one of the most common reasons for revision surgery after primary total hip arthroplasty. Both patient related and surgical factors may influence the risk of dislocation. In this study, we evaluated risk factors for dislocation revision after total hip arthroplasty based on revised data contents of the Finnish Arthroplasty Register. METHODS: We analyzed 33,337 primary total hip arthroplasties performed between May 2014 and January 2018 in Finland. Cox proportional hazards regression was used to estimate hazard ratios with 95% confidence intervals for first dislocation revision using 18 potential risk factors as covariates, such as age, sex, diagnosis, hospital volume, surgical approach, head size, body mass index, American Society of Anesthesiology class, and fixation method. RESULTS: During the study period, there were 264 first-time revisions for dislocation after primary total hip arthroplasty. The hazard ratio for dislocation revision was 3.1 (confidence interval 1.7-5.5) for posterior compared to anterolateral approach, 3.0 (confidence interval 1.9-4.7) for total hip arthroplasties performed for femoral neck fracture compared to total hip arthroplasties performed for osteoarthritis, 2.0 (confidence interval 1.0-3.9) for American Society of Anesthesiology class III-IV compared to American Society of Anesthesiology class I, and 0.5 (0.4-0.7) for 36-mm femoral head size compared to 32-mm head size. CONCLUSIONS: Special attention should be paid to patients with fracture diagnoses and American Society of Anesthesiology class III-IV. Anterolateral approach and 36-mm femoral heads decrease dislocation revision risk and should be considered for high-risk patients.

Cementing does not increase the immediate postoperative risk of death after total hip arthroplasty or hemiarthroplasty: a hospital-based study of 10,677 patients.

Background and purpose - It has been suggested that cemented arthroplasty is associated with increased peri- and postoperative mortality due to bone cement implanting syndrome, especially in fracture surgery. We investigated such an association in elective total hip arthroplasty (THA) patients and hemiarthroplasty (HA) patients treated for femoral neck fracture. Patients and methods - All 10,677 patients receiving elective THA or HA for fracture in our hospital between 2004 and 2015 were identified. Mortality rates for cemented and uncemented THA and HA were compared at different times postoperatively using logistic regression analysis. Analysis was adjusted for age, sex, ASA class, and year of surgery. Results - Adjusted 10- and 30-day mortality after cemented THA was comparable to that of the uncemented THA (OR 1.7; 95% CI 0.3-8.7 and OR 1.6; CI 0.7-3.6, respectively). There was no statistically significant difference in the adjusted 2-day mortality in the cemented HA group when compared with the uncemented group. However, in a subgroup analyses of ASA-class IV HA patients there was a difference, statistically not significant, during the first 2 days postoperatively in the cemented HA group compared with the uncemented HA group (OR 2.1; CI 0.9-4.7). Interpretation - Cementing may still be a safe option in both elective and hip fracture arthroplasty. Excess mortality of cemented THA and HA in the longer term is comorbidity related, not due to bone cement implantation syndrome. However, in the most fragile HA patient group caution is needed at the moment of cementing.

Early postoperative mortality similar between cemented and uncemented hip arthroplasty: a register study based on Finnish national data.

Background and purpose - Implant survival of cemented total hip arthroplasty (THA) in elderly patients is higher than that of uncemented THA. However, a higher mortality rate in patients undergoing cemented THA compared with uncemented or hybrid THA has been reported. We assessed whether cemented fixation increases peri- or early postoperative mortality compared with uncemented and hybrid THA. Patients and methods - Patients with osteoarthritis who received a primary THA in Finland between 1998 and 2013 were identified from the PERFECT database of the National Institute for Health and Welfare in Finland. Definitive data on fixation method and comorbidities were available for 62,221 THAs. Mortality adjusted for fixation method, sex, age group, and comorbidities among the cemented, uncemented, and hybrid THA was examined using logistic regression analysis. Reasons for cardiovascular death within 90 days since the index procedure were extracted from the national Causes of Death Statistics and assessed separately. Results - 1- to 2-day adjusted mortality after cemented THA was comparable to that of the uncemented THA group (OR 1.2; 95% CI 0.24-6.5). 3- to 10-day mortality in the cemented THA group was comparable to that in the uncemented THA group (OR 0.54; CI 0.26-1.1), and in the hybrid THA group (OR 0.64, CI 0.25-1.6). Pulmonary embolism or cardiovascular reasons as a cause of death were not over-represented in the cemented THA group. Interpretation - Early peri- and postoperative mortality in the cemented THA group was similar compared with that of the hybrid and uncemented groups.

Midterm risk of cancer with metal-on-metal hip replacements not increased in a Finnish population.

Background and purpose - Metal-on-metal (MoM) total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA) have been widely used during the early 21st century. We assessed the midterm risk of cancer of patients treated with modern MoM hip implants compared with patients with non-MoM hip implants and the general Finnish population with special interest in soft tissue sarcomas and basalioma due to the findings of our previous report. Patients and methods - All large-diameter head MoM THAs and hip resurfacings performed in Finland between 2001 and 2010 were extracted from the Finnish Arthroplasty Register (10,728 patients). Patients who underwent conventional THA formed the non-MoM reference cohort (18,235 patients). Data on cancer cases up to 2014 were extracted from the Finnish Cancer Registry. The relative risk of cancer in the general population was expressed as the ratio of observed to expected number of cases, i.e., standardized incidence ratio (SIR). Poisson regression analysis was used to compare the cancer risk between the cohorts. The mean follow-up was 7.4 years (1-14) in the MoM cohort and 8.4 years (1-14) in the non-MoM cohort. Results - The overall risk of cancer in the MoM cohort was comparable to the general Finnish population (SIR 0.9, 95% CI 0.9-1.0). Risk of basalioma in the MoM cohort was higher than in the general Finnish population (SIR 1.2, CI 1.1-1.4) and higher than in the non-MoM cohort in the stratified regression analysis (RR 1.2, CI 1.0-1.4, p = 0.02). The SIR of soft-tissue sarcoma in the MoM cohort was 1.4 (CI 0.6-2.8); the incidence was same as in the non-MoM cohort. Interpretation - Metal-on-metal hip implants are not associated with an increased overall risk of cancer during midterm follow-up.

Favourable long-term functional and radiographical outcome after osteoautograft transplantation surgery of the knee: a minimum 10-year follow-up.

PURPOSE: The aim of this study was to assess the progression of radiological cartilage changes and to document the functional, long-term results during a follow-up of 10 years after osteoautograft transplantation (OAT) knee surgery. METHODS: The study was a retrospective analysis of all patients who underwent OAT at Turku University Hospital from 1999 to 2007. Pre- and postoperative cartilage changes were estimated based on standardised radiographs. The extent of osteoarthritis (OA) was graded according to the Kellgren-Lawrence scale. Clinical outcomes were evaluated with the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire. RESULTS: A total of 60 patients (64 knees) with a median age of 30 years (range 14-62) were included. The median follow-up was 140 months (range 47-205). Of the 64 knees examined, 14 (22%) had a traumatic chondral lesion and 50 (78%) had osteochondritis dissecans (OCD). Preoperatively, 71% of the patients had Kellgren-Lawrence grades of 0-1; during the follow-up period, 50% of the patients showed radiographical progression of OA. OA progressed most significantly in patients with normal preoperative Kellgren-Lawrence grades (p = 0.0003). Patients with no progression in joint space narrowing had statistically significantly better overall KOOS (p = 0.02) than patients whose Kellgren-Lawrence grades worsened. Patients with defect sizes > 3.0 cm2 scored statistically significantly better in all subscales than patients with smaller defect sizes (p = 0.02). Patients with OCD had statistically significantly better KOOS than patients with chondral defects (p = 0.008). CONCLUSIONS: OAT surgery for treating patients with cartilage defects of the knee had good clinical results after a mean follow-up of 11 years. Radiological analyses revealed a progression of cartilage degeneration in 50% of the operated knees. Patients with no progression of the degenerative changes scored statistically significantly better on the KOOS self-assessment test. These results indicate that OAT surgery appears to be a reasonable therapeutic option to restore knee function in patients with cartilage lesions. LEVEL OF EVIDENCE: IV.