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Background: Few randomized controlled trials have compared operative with nonoperative treatment of clavicular fractures.Methods: Patients with displaced midshaft clavicular fractures were randomized either to nonoperative treatment with a sling or to operative treatment with a stainless steel 3.5-mm reconstruction plate. Outcome measures were the Constant shoulder score, DASH (Disabilities of the Arm, Shoulder and Hand) score, pain, fracture-healing, and complications. The null hypothesis was that the Constant and DASH scores would not differ between the groups at the one-year follow-up evaluation.Results: In accordance with the power analysis, we included sixty patients in the study; thirty-two were randomized to the nonoperative group and twenty-eight to the operative group. We found no difference in the Constant score (p = 0.75), the DASH score (p = 0.89), or pain (p = 0.98) between the groups at the one-year follow-up evaluation. All fractures in the operative group healed, but six nonunions (24%) occurred in the nonoperative group.Conclusions: One year after a displaced midshaft clavicular fracture, nonoperative treatment resulted in a higher nonunion rate but similar function and disability compared with operative treatment. [ABSTRACT FROM AUTHOR]

The objectives of the present study were to find out the results and the factors affecting survival after primary knee arthroplasty with a cruciate-retaining prosthesis in severe valgus deformity. Forty-eight patients (52 knees) participated in the current follow-up study. All patients were followed at least 5 years or to first revision. Mean follow-up time was 9 years (range, 1 to 17 years).The Kaplan-Meier analysis revealed 79% (95% CI 68% to 91%) survival rate with revision for any reason and 81% (95% CI 70% to 93%) survival rate with revision for instability as an endpoint at 10 years. Preoperatively TFA was 23° (range, 15°-51°) in valgus and 7° (range, 21° valgus-4° varus) in valgus postoperatively. Of the 14 re-operated patients, eight were revised because of progressive postoperative medial collateral ligament instability. All re-operations were performed during the first 4 years of the follow-up. The mean TFA was 15.5° valgus postoperatively for those eight and the odds ratio for a revision was 2 (95% CI 1-3, p = 0.025) when compared to the rest of the study population. The residual valgus deformity increases the risk of re-operation and it should be avoided. If proper soft-tissue balance cannot be achieved or there is no functional medial collateral ligament present more constrained implants should be used. In selected cases where both bony correction and ligament balancing have properly been achieved the use of a cruciate-retaining type of prosthesis is justified. [ABSTRACT FROM AUTHOR]

Background Cemented total hip arthroplasty has been the treatment of choice for elderly patients with osteoarthritis. We analyzed survival rates of the most common cementless designs used in this age group in Finland. Patients and methods Inclusion criteria permitted 10,310 replacements (8 designs) performed in patients aged 55 years or older to be selected for evaluation. The risk of revision of each of the 8 implants was compared with that of a group comprising 3 cemented designs as the reference (9,549 replacements). Survival analyses were performed overall and separately for 3 age cohorts: 55-64 years (6,781 replacements), 65-74 years (8,821 replacements), and 75 years or older (4,257 replacements). Results In all patients aged 55 years or more, the Bi-Metric stem had a higher survival rate for aseptic loosening at 15 years than the cemented reference group: 96% (95% CI: 94-98) vs. 91% (CI: 90-92). However, the 15-year survival rates of the Bi-Metric/Press-Fit Universal (71% (CI: 67-75)) and the Anatomic Mesh/Harris-Galante II (72% (CI: 67-78)) total hip replacements were lower than that of the reference group (86% (CI: 84-87)). Information was scarce for patients aged 75 years or more. Interpretation Cementless proximal porous-coated stems are a good option for elderly patients. Even though biological fixation is a reliable fixation method in THA, polyethylene wear and osteolysis remain a serious problem for cementless cup designs with unplugged screw holes and low-quality liners. [ABSTRACT FROM AUTHOR]

Study Design: A long-term, population based, retrospective follow-up study. Objective: To evaluate long-term outcomes of brace and surgical treatment for spinal deformities in patients with diastrophic dysplasia (DD). Summary Of Background Data: Literature on the brace treatment and surgery of spinal deformities in patients with DD is limited. Methods: All patients with DD undergoing either brace treatment or surgery for spinal deformity with a minimum of 2 years follow-up were identified in our country. Eight patients had undergone brace treatment and 12 had been treated operatively. Two patients had early progressive and the rest idiopathic-like scoliosis. Five patients underwent posterior only, 1 anterior only, and 6 anteroposterior surgery. Patients' mean age at the beginning of brace treatment was 6.9 (range, 0.9-12.7) years and at the time of surgery 13.4 (range, 6.5-20.1) years. The follow-up time averaged 17 (range, 6.6-44.3) years for the brace and 14.0 (range, 2.1-37.2) years for the surgical treatment group. The radiographic follow-up rate was 100%. Results: Both thoracic and lumbar curves progressed during brace treatment (mean major curve progression 12%, range, -43%-53%). Before surgery, the mean Cobb angle of the thoracic curve was 68 degrees (range, 42 degrees-100 degrees) and 46 degrees (25 degrees-68 degrees) in the lumbar spine. At final follow-up visit, the mean correction was 23% (-6%-76%) for the thoracic curve and 25% (-68%-82%) for the lumbar curve. The correction of the major curve was higher in patients undergoing anteroposterior versus posterior only (40% vs. 13%, P = 0.017). Five (42%) operated patients had significant complications. The SRS-24 yielded 92 (79-103) points for the brace treatment and 93 (73-114) points for the surgical group, respectively. Conclusion: Brace treatment does not prevent progression of the spinal deformity in patients with DD. Anteroposterior surgery is indicated in patients with severe spinal deformities. The risk for major complications is high especially in patients with marked kyphosis. [ABSTRACT FROM AUTHOR]

Background and purpose Historically, a Schanz osteotomy of the femur has been used to reduce limp in patients with severely dysplastic hips. In such hips, total hip arthroplasty is a technically demanding operation. We report the long-term results of cementless total hip arthroplasty in a group of patients who had all undergone a Schanz osteotomy earlier. Patients and methods From 1988 through 1995, 68 total hip replacements were performed in 59 consecutive patients previously treated with a Schanz osteotomy. With the cup placed at the level of the true acetabulum, a shortening osteotomy of the proximal part of the femur and distal advancement of the greater trochanter were performed in 56 hips. At a mean of 13 (9-18) years postoperatively, we evaluated these patients clinically and radiographically. Results The mean Harris hip score had increased from 51 points preoperatively to 93 points. Trendelenburg sign was negative and there was good or slightly reduced abduction strength in 23 of 25 hips that had not been revised. There were 12 perioperative complications. Only 1 cementless press-fit porous-coated cup was revised for aseptic loosening. However, the 12-year survival rate of these cups was only 64%, as 18 cups underwent revision for excessive wear of the polyethylene liner and/or osteolysis. 6 CDH femoral components had to be revised due to technical errors. Interpretation Our results suggest that cementless total hip arthroplasty combined with a shortening osteotomy of the femur and distal advancement of the greater trochanter can be recommended for most patients with a previous Schanz osteotomy of the femur. Because of the high incidence of liner wear and osteolysIacutes of modular cementless cups in this series, nowadays we use hard-on-hard articulations in these patients. [ABSTRACT FROM AUTHOR]

Background: According to the long-term results obtained from the Scandinavian arthroplasty registries, cemented total hip replacement has been the treatment of choice for osteoarthritis of the hip in elderly patients. The aim of the present study was to analyze population-based survival rates of the cemented and cementless total hip replacements performed for primary osteoarthritis in patients fifty-five years of age or older in Finland.Methods: From 1980 to 2004, a total of 50,968 primary total hip replacements that met our criteria were entered in the Finnish Arthroplasty Registry. The success rate of different implant groups was analyzed. The implants included were classified in one of the following four groups: implants with a cementless, straight, proximally circumferentially porous-coated stem and a modular, porous-coated press-fit cup (cementless group 1); implants with a cementless, anatomic, proximally circumferentially porous-coated and/or hydroxyapatite-coated stem with a modular, porous-coated and/or hydroxyapatite-coated press-fit cup (cementless group 2); a hybrid total hip replacement consisting of a cemented stem combined with a modular, press-fit cup (the hybrid group); and a cemented loaded-taper or composite-beam stem combined with an all-polyethylene cup (the cemented group).Results: Cementless total hip replacements, as well as cementless stems and cups analyzed separately, had a significantly reduced risk of revision for aseptic loosening compared with cemented hip replacements (p < 0.001). When revision for any reason was the end point in survival analyses, however, there were no significant differences among the groups. In patients between the ages of fifty-five and sixty-four years, the fifteen-year survival rates of the two cementless groups (78% and 80%) were higher than that of the cemented group (71%) with revision for aseptic loosening as the end point. In patients who were sixty-five to seventy-four years old, the fifteen-year survival rate of the implants in cementless group 1 was 94%, while cemented total hip replacements had an 85% survival rate. In patients who were seventy-five years old or more, no significant differences were detected among the total hip replacement groups; all of them had survivorship of >90% at ten years.Conclusions: In patients who were fifty-five years of age or older, the long-term survival of cementless total hip replacements was comparable with that of cemented replacements. In patients who were fifty-five to seventy-four years old, straight porous-coated cementless stems had better long-term survival than the cemented stems. In patients who were seventy-five years of age and older, there were no significant differences in the results. Multiple wear-related revisions of the cementless cups in the present study indicate that excessive polyethylene wear was a major clinical problem with modular cementless cups in all age groups.Level Of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Intermediate-term radiographic studies have shown that anterior and circumferential techniques result in high fusion rates in patients with high-grade spondylolisthesis, whereas posterolateral fusion is less successful. We are not aware of any long-term comparative studies in which these three methods have been evaluated with regard to functional outcome, including systematic spinal mobility and trunk strength measurements.Methods: Sixty-nine of eighty-three consecutive patients with high-grade isthmic spondylolisthesis who underwent posterolateral (twenty-one), anterior (twenty-three), or circumferential (twenty-five) uninstrumented spondylodesis between 1977 and 1991 participated in the study. The average duration of follow-up was 17.2 years. Radiographs that were made preoperatively and at the time of the most recent follow-up were assessed with regard to fusion quality and degenerative changes. Outcome was assessed at the time of the most recent follow-up by independent observers on the basis of a physical examination, spinal mobility and nondynamometric trunk strength measurements, and Oswestry Disability Index scores.Results: The mean preoperative vertebral slip was 61% in the posterolateral fusion group, 63% in the anterior fusion group, and 71% in the circumferential fusion group. The final fusion rate was 86% (eighteen of twenty-one) in the posterolateral fusion group, 100% (twenty-three of twenty-three) in the anterior fusion group, and 96% (twenty-four of twenty-five) in the circumferential fusion group. A decrease in lumbar intervertebral disc height at the first mobile level superior to the fusion was noted in five patients in the posterolateral fusion group, seven patients in the anterior fusion group, and one patient in the circumferential fusion group (p = 0.037). The mean Oswestry Disability Index score was 9.7 for the posterolateral fusion group, 8.9 for the anterior fusion group, and 3.0 for the circumferential fusion group (p = 0.035). Nondynamometric trunk strength measurements corresponded with referential values. Abnormally low lumbar flexion affected the posterolateral and circumferential fusion groups more often than the anterior fusion group (p = 0.0015). The percentage of slip showed inverse correlations with lumbar flexion, lumbar extension, and trunk side-bending.Conclusions: As assessed on the basis of patient-based outcomes, circumferential in situ fusion provided slightly better long-term results than did posterolateral or anterior in situ fusion. When the radiographic and functional results were combined with the patient-based outcomes, the overall differences between the three groups were small. [ABSTRACT FROM AUTHOR]

BACKGROUND: Since our previous study in 1997, three of five medical schools have introduced clinical skills centres. AIMS: Aim of the present follow-up study was to assess the present status of emergency procedure skills teaching. The number of students having practical experience of the procedures and student satisfaction were used as outcome. METHOD: An electronic questionnaire including questions concerning successful performance of eleven emergency procedures and experiences in a clinical skills centre was sent to all final year medical students in all five Finnish medical faculties. The students were asked to give global rating for the volume and quality of emergency procedural skills. The response rate was 304/448 (67.8%). RESULTS: There were significant differences in theoretical knowledge and practical performance of procedures between students in different medical schools. The students in the university having integrated curriculum and longest experience of a clinical skills centre were most satisfied with the volume and quality of emergency procedural skills teaching (p<0.001). They also found practicing in a skills lab more useful than students in other medical schools (p<0.026). CONCLUSIONS: The students' experience of emergency procedure has slightly improved. Early practising in a clinical skills centre seems to increase the student satisfaction with emergency skills education. [ABSTRACT FROM AUTHOR]

Background: Intermediate-term radiographic studies have shown that anterior and circumferential techniques result in high fusion rates in patients with high-grade spondylolisthesis, whereas posterolateral fusion is less successful. We are not aware of any long-term comparative studies in which these three methods have been evaluated with regard to functional outcome, including systematic spinal mobility and trunk strength measurements.Methods: Sixty-nine of eighty-three consecutive patients with high-grade isthmic spondylolisthesis who underwent posterolateral (twenty-one), anterior (twenty-three), or circumferential (twenty-five) uninstrumented spondylodesis between 1977 and 1991 participated in the study. The average duration of follow-up was 17.2 years. Radiographs that were made preoperatively and at the time of the most recent follow-up were assessed with regard to fusion quality and degenerative changes. Outcome was assessed at the time of the most recent follow-up by independent observers on the basis of a physical examination, spinal mobility and nondynamometric trunk strength measurements, and Oswestry Disability Index scores.Results: The mean preoperative vertebral slip was 61% in the posterolateral fusion group, 63% in the anterior fusion group, and 71% in the circumferential fusion group. The final fusion rate was 86% (eighteen of twenty-one) in the posterolateral fusion group, 100% (twenty-three of twenty-three) in the anterior fusion group, and 96% (twenty-four of twenty-five) in the circumferential fusion group. A decrease in lumbar intervertebral disc height at the first mobile level superior to the fusion was noted in five patients in the posterolateral fusion group, seven patients in the anterior fusion group, and one patient in the circumferential fusion group (p = 0.037). The mean Oswestry Disability Index score was 9.7 for the posterolateral fusion group, 8.9 for the anterior fusion group, and 3.0 for the circumferential fusion group (p = 0.035). Nondynamometric trunk strength measurements corresponded with referential values. Abnormally low lumbar flexion affected the posterolateral and circumferential fusion groups more often than the anterior fusion group (p = 0.0015). The percentage of slip showed inverse correlations with lumbar flexion, lumbar extension, and trunk side-bending.Conclusions: As assessed on the basis of patient-based outcomes, circumferential in situ fusion provided slightly better long-term results than did posterolateral or anterior in situ fusion. When the radiographic and functional results were combined with the patient-based outcomes, the overall differences between the three groups were small. [ABSTRACT FROM AUTHOR]

Background: The long-term results of surgical treatment of brachial plexus birth palsy have not been reported. We present the findings of a nationwide study, with a minimum five-year follow-up, of the outcomes of surgery for brachial plexus birth palsy in Finland.Methods: Of 1,717,057 newborns, 1706 with brachial plexus birth palsy requiring hospital treatment were registered in Finland between 1971 and 1997. Of these patients, 124 (7.3%) underwent surgery on the brachial plexus at a mean age of 2.8 months (range, 0.4 to 13.2 months). The most commonly performed surgical procedure was direct neurorrhaphy after neuroma resection. One hundred and twelve patients (90%) returned for a clinical and radiographic follow-up examination after a mean of 13.3 years. Activities of daily living were recorded on a questionnaire, and the affected limb was assessed with use of joint-specific functional measures.Results: Two-thirds (63%) of the patients were satisfied with the functional outcome, although one-third of all patients needed help in activities of daily living. One-third of the patients, including all nine with a clavicular nonunion from the surgical approach, experienced pain in the affected limb. All except four patients used the hand of the unaffected limb as the dominant hand. Shoulder function was moderate, with a mean Mallet score of 3.0. Both elbow and hand function were good, with a mean score on the Gilbert elbow scale of 3 and a mean Raimondi hand score of 4. Incongruence of the glenohumeral joint was noted in sixteen (16%) of the ninety-nine patients in whom it was assessed, and incongruence of the radiohumeral joint was noted in twenty-one (21%). The extent of the brachial plexus injury was found to be strongly associated with the final shoulder, elbow, and hand function in a multivariate analysis.Conclusions: Following surgical treatment of brachial plexus birth palsy, substantial numbers of the patients continued to need help performing activities of daily living and had pain in the affected limb, with the pain due to a clavicular nonunion in one-fourth of the patients. The strongest prognostic factor predicting outcome appears to be the extent of the primary plexus injury. [ABSTRACT FROM AUTHOR]

Background The results of total hip arthroplasty (THA) in young patients with rheumatoid arthritis (RA) have been reported in only a few studies. On a nationwide level, the outcome of THA in these patients is unknown. We evaluated the population-based survival of THA in patients under 55 years of age with RA and factors affecting the survival. Patients Between 1980 and 2003, 2,557 primary THAs performed for RA in patients less than 55 years of age were reported to the Finnish Arthroplasty Register. Results Proximally circumferentially porous-coated uncemented stems had a 15-year survival rate of 89% (95% CI 83-94) with aseptic loosening as endpoint. The risk of stem revision due to aseptic loosening was higher with cemented stems than with proximally porouscoated uncemented stems implanted during the same period (RR 2.4; p < 0.001). In contrast, Cox regression analysis showed that the risk of cup revision was significantly higher for all uncemented cup concepts than for all-polyethylene cemented cups with any cup revision as endpoint. There were no significant differences in survival between the THR concepts. Interpretations Uncemented proximally circumferentially porous-coated stems and cemented all-poly-ethylene cups are currently the implants of choice for young patients with RA. [ABSTRACT FROM AUTHOR]

Background: The optimal surgical treatment for patients with high congenital dislocation of the hip remains controversial. The purpose of our study was to evaluate the mid-term to long-term results of cementless total hip arthroplasty in such patients.Methods: The study included sixty-eight total hip replacements performed between 1989 and 1994 in fifty-six consecutive patients with high congenital hip dislocation at our hospital. The cup was placed at the level of the true acetabulum, and a shortening osteotomy of the proximal part of the femur and distal advancement of the greater trochanter were performed in 90% of the hips. At the time of final follow-up, at a mean of 12.3 years postoperatively, fifty-two patients (sixty-four hips) were evaluated by us with a physical examination, determination of Harris hip scores, and radiographs.Results: The mean Harris hip score increased from 54 points preoperatively to 84 points at the time of final follow-up (p < 0.001). There was a negative Trendelenburg sign in fifty-nine (92%) of the sixty-four hips. There were thirteen perioperative complications (19%): three peroneal nerve palsies, one femoral nerve palsy, one superior gluteal nerve palsy, four nondisplaced fractures of the proximal part of the femur, one malpositioned stem perforating the posteromedial cortex of the femur, one superficial wound infection, and two early dislocations. With revision because of aseptic loosening as the end point, the ten-year survival rate for press-fit, porous-coated acetabular components was 94.9% (95% confidence interval, 89.3% to 100%). Eight of nine threaded acetabular components were revised, and the ninth was radiographically loose at the time of the last follow-up examination. The rate of survival for the CDH femoral components, with revision because of aseptic loosening as the end point, was 98.4% (95% confidence interval, 96.8% to 100%) at ten years.Conclusions: Total hip arthroplasty, with placement of the cup at the level of the true acetabulum, distal advancement of the greater trochanter, and femoral shortening osteotomy, can be recommended for patients with high congenital hip dislocation. Complications such as wear, osteolysis, and cup revision were secondary to the suboptimal design of the acetabular components used in this series. [ABSTRACT FROM AUTHOR]

Controlled clinical trials on the effects of leukotriene antagonists on asthma-like symptoms, bronchial hyperresponsiveness and airway inflammation have not been performed in elite athletes. In 2001, we examined 88 of 102 (86%) players from three junior, national league ice hockey teams in Helsinki. Athletes were included in the intervention if they reported at least two exercise-induced bronchial symptoms (wheeze, cough, shortness of breath) weekly during the previous month on a previously validated respiratory-symptom questionnaire. Sixteen male ice hockey players fulfilled the study criteria. A double-blind, randomized, cross-over, placebo-controlled study included 4-week active treatment (10 mg oral montelukast, bedtime), 1-week washout period, and 4-week placebo treatment. Before entering the study, all patients were clinically examined, skin prick tested, filled in a respiratory symptom questionnaire, performed a spirometry and a histamine challenge test, and gave induced sputum samples. Exhaled NO was measured. These measures were repeated after both treatment periods. During the treatment the athletes kept daily diary on lower respiratory tract symptoms on a scale from 0 (no symptoms) to 10 (most severe symptoms), morning peak expiratory flow (PEF), training amount, and use of study medication. Primary end-point was daily lower respiratory tract symptom score. Montelukast had no effect on daily lower respiratory symptom scores, spirometry parameters [forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, PEF], bronchial hyperresponsiveness, sputum eosinophil or neutrophil cell counts, exhaled NO measurements, or morning PEF. Nine subjects were atopic in skin prick test, but their results did not differ from the nonatopic subjects. A leukotriene antagonist, montelukast, was of no benefit in the treatment of asthma-like symptoms, increased bronchial hyperresponsiveness or a mixed type of eosinophilic and neutrophilic airway inflammation in highly-trained ice hockey players. [ABSTRACT FROM AUTHOR]

Background: Previous studies have shown that the long-term clinical outcome does not correlate with the radiographic outcome in patients treated with Harrington instrumentation for adolescent idiopathic scoliosis. Cotrel-Dubousset instrumentation has been reported to provide better correction radiographically, but it is unclear whether it provides better long-term clinical or functional outcomes. We are not aware of any long-term studies comparing Harrington and Cotrel-Dubousset instrumentation.Methods: Seventy-eight patients in whom adolescent idiopathic scoliosis was treated with Harrington instrumentation and fifty-seven in whom it was treated with Cotrel-Dubousset instrumentation participated in this study. The mean duration of follow-up was 20.8 years for the Harrington instrumentation group and 13.0 years for the Cotrel-Dubousset instrumentation group. The mean age at the time of follow-up was thirty-six years and twenty-eight years, respectively. Radiographs were made preoperatively and at the two-year and final follow-up examinations. The Scoliosis Research Society questionnaire was completed, a physical examination was performed, and spinal mobility and non-dynamometric trunk strength were measured at the final follow-up visit.Results: The mean preoperative Cobb angle of the thoracic curves was 53 degrees in the Harrington instrumentation group and 55 degrees in the Cotrel-Dubousset instrumentation group. The mean numbers of vertebrae included in the instrumentation were 10.7 and 9.9, respectively. At the two-year follow-up evaluation, the mean postoperative Cobb angles were 38 degrees and 25 degrees, respectively (p < 0.0001). At the final follow-up evaluation, the mean angles were 45 degrees and 32 degrees (p < 0.0001). No significant difference in thoracic kyphosis or lumbar lordosis was observed between the study groups at the final follow-up evaluation. The average score on the Scoliosis Research Society questionnaire was 97 points in both groups. Measurements of non-dynamometric trunk strength corresponded with age and sex-adjusted reference values, on the average, but patients with Cotrel-Dubousset instrumentation performed significantly better in the squatting test (p = 0.010). Abnormal lumbar extension and trunk side-bending were significantly more common in the Harrington instrumentation group (p = 0.050 and p = 0.0061, respectively). Complications were recorded for nine (12%) of the patients treated with Harrington instrumentation and fifteen (26%) of those treated with Cotrel-Dubousset instrumentation (p = 0.027).Conclusions: Cotrel-Dubousset instrumentation yielded better long-term functional and radiographic outcomes in patients with adolescent idiopathic scoliosis than did Harrington instrumentation. However, complications were more common in the Cotrel-Dubousset instrumentation group. [ABSTRACT FROM AUTHOR]