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Background Short and midterm mortality of patients with osteoarthritis (OA) who have undergone total knee arthroplasty (TKA) is generally lower than that of the general population. Due to an increasing number of young patients who undergo TKA the expected lifetime of these patients is increasing. The purpose of this study was to assess the causes of death and long-term mortality among Finnish TKA patients. Methods Standardized mortality ratios (SMRs) for total and site specific causes of death were calculated for 9443 TKA patients operated on in 1980 to 1996 for OA and followed until 2012. Results The mean follow-up time was 14 years (maximum 33 years). During follow-up, 77% of the patients had died. The all-cause SMR was 1.00. It was significantly lower than in the reference population (SMR 0.73) during the first 10 years after operation, but higher during the next 10 years (SMR 1.23), and even more after 20 years (SMR 1.95). The SMR for cardiovascular mortality was 1.03 and accounted for 52% of all deaths. Significant excess mortality was observed in diseases of the digestive tract (SMR 1.29). Deaths due to cardiovascular diseases, Alzheimer's disease and dementia comprised 68% of all deaths that took place 10 years or later after TKA. Conclusions The mortality of TKA patients with OA is significantly reduced during the first 10 postoperative years but exceeds the mortality of the general population after that. This trend should be taken into account when young patients undergo a TKA. Level of evidence Observational study, III.

Background and purpose Wear debris from conventional total hip arthroplasty (THA) induces chromosomal aberrations and DNA damage, which may promote cancerogenesis. A long latent period is required for solid tumors. We therefore re-analyzed a large THA cohort for cancer.Patients and methods We updated a cohort of 24,636 patients with primary osteoarthritis and metal-on-polyethylene THA who had been entered in the Finnish Arthroplasty Register between 1980 and 1995, and linked it to the Finnish Cancer Registry for cancer risk assessment up to 2005. The mean follow-up time was 13 years. The numbers of cancer cases observed were compared with expected rates based on incidence in the general population.Results The standardized incidence ratio (SIR) for the whole follow-up period was 0.95 (95% confidence interval (CI): 0.92–0.97). After 10 years of follow-up, the SIR was equal to that in the normal population (SIR = 0.98, 95% CI: 0.94–1.03). Incidence of lung cancer was low throughout the follow-up time and tha...

BACKGROUND: Surgical treatment of Osgood-Schlatter disease is occasionally warranted, but its long-term prognosis remains poorly investigated. We studied the rate of occurrence of surgical treatment of unresolved Osgood-Schlatter disease as well as the clinical course, radiographic characteristics, and long-term outcomes after that treatment in a large population of military recruits. METHODS: During a thirteen-year period, 178 consecutive recruits underwent surgery for unresolved Osgood-Schlatter disease, and 107 of them (117 knees) who met the inclusion criteria participated in a follow-up examination. We obtained data from the original medical records and radiographs as well as follow-up information from physical and radiographic examinations, interviews, and questionnaires to determine functional outcomes. RESULTS: The rate of occurrence of surgically treated unresolved Osgood-Schlatter disease was forty-two per 100,000 military recruits. The median age at the onset of symptoms was fifteen years. After a median duration of follow-up of ten years after the surgery, ninety-three patients (87%) reported no restrictions in everyday activities or at work and eighty (75%) had returned to their preoperative level of sports activity. The median modified Kujala score was 95 points, and the median visual analog score for pain was 7 mm. Forty-one patients (38%) reported a complete absence of pain when kneeling. Six patients had experienced minor postoperative complications, and two had undergone a reoperation for the treatment of the Osgood-Schlatter disease. After resection, the mean tibial tuberosity thickness decreased by 47%. The mean Insall-Salvati index was 1.0 preoperatively and 1.09 postoperatively (p = 0.003), and the corresponding mean Blackburne-Peel indexes were 0.85 and 0.95 (p = 0.003). With the numbers studied, the symptom duration, surgical methods, and radiographic indexes were not found to have an effect on the outcome of surgery. CONCLUSIONS: In the great majority of young adults, the functional outcome of surgical treatment of unresolved Osgood-Schlatter disease is excellent or good, the residual pain intensity is low, and postoperative complications or subsequent reoperations are rare. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. ORIGINAL ABSTRACT CITATION: “Long-Term Outcome After Surgical Treatment of Unresolved Osgood-Schlatter Disease in Young Men” (2009;91:2350-8).

There is no consensus about the management of acute primary traumatic patellar dislocation in young physically active adults. The objective of this study was to compare the clinical outcomes after treatment with and without initial stabilizing surgery for primary traumatic patellar dislocation in young adults.Forty young adults, thirty-seven men and three women with a median age of twenty years (range, nineteen to twenty-two years), who had an acute primary traumatic patellar dislocation were randomly allocated to be treated with initial surgical stabilization (eighteen patients, with each receiving one of two types of initial stabilizing procedures) or to be managed with an orthosis (twenty-two patients, including four who had osteochondral fragments removed arthroscopically). After a median of seven years, thirty-eight patients returned for a follow-up examination. Redislocations, subjective symptoms, and functional limitations were evaluated. Radiographs and magnetic resonance images were obtained at the time of randomization, and twenty-nine (76%) patients underwent magnetic resonance imaging at the time of final follow-up.A hemarthrosis as well as injuries of the medial retinaculum and the medial patellofemoral ligament were found on magnetic resonance imaging in all patients at the time of randomization. During the follow-up period, six of the twenty-one nonoperatively treated patients and none of the seventeen patients treated with surgical stabilization had a redislocation (p = 0.02). Four nonoperatively treated patients and two patients treated with surgical stabilization reported painful patellar subluxation. The median Kujala scores were 91 points for the surgically treated patients and 90 points for the nonoperatively treated patients. Thirteen patients in the surgically treated group and fifteen in the nonoperatively treated group regained their former physical activity level. At the time of follow-up, a full-thickness patellofemoral articular cartilage lesion was detected on magnetic resonance imaging in eleven patients; the lesions were considered to be unrelated to the form of treatment.In a study of young, mostly male adults with primary traumatic patellar dislocation, the rate of redislocation for those treated with surgical stabilization was significantly lower than the rate for those treated without surgical stabilization. However, no clear subjective benefits of initial stabilizing surgery were seen at the time of long-term follow-up.

BackgroundNo data exist whether patients with primary traumatic patellar dislocation benefit from initial arthroscopic medial repair surgery.PurposeTo compare long-term outcomes of patients treated with acute arthroscopic stabilization for patellar dislocation with those treated nonoperatively except for removal of loose bodies.Study DesignCohort study; Level of evidence, 2.MethodsThe study group included 76 consecutive military recruits (72 men, 4 women), with a median age of 20 years (range, 19–22) at the time of dislocation. Thirty patients (group 1) underwent initial arthroscopic medial retinacular repair, and 46 patients (group 2) were treated without stabilizing surgery, including 11 who had osteochondral fragments arthroscopically removed. Patients with previous patellar dislocations or instability were excluded. Aftercare was identical in both groups. Redislocations, subjective symptoms, and functional limitations were evaluated after a median 7-year follow-up.ResultsSixty-one (80%) patients participated in a follow-up examination. At final follow-up, 8 (23%) redislocations occurred in group 2 and 5 (19%) in group 1 ( P = .84). Eight (23%) patients in group 2 and 3 (12%) in group 1 reported patellar subluxations ( P = .18). In group 1, 81% regained their preinjury activity level compared with 56% in group 2 ( P = .05). Functional outcomes were good in both groups (Kujala scores: 87 for group 1 and 90 for group 2) ( P = .22). Regarding the presence of osteoarthritic characteristics in the patellofemoral joint, no statistically significant differences were found between the groups.ConclusionsInitial arthroscopic medial retinacular repair was not followed by improved patellar stability nor reduced incidence of redislocations compared with nonoperative (except for removal of loose bodies) treatment. Acute arthroscopic medial retinacular repair allowed patients to better regain preinjury activity level than in patients not undergoing retinacular repair. The decision to stabilize the patella by initial arthroscopic surgery should be made with caution.

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.

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

During the years 1974 to 2003, a total of 46 cases of malignant tumors at the site of total hip arthroplasty, 41 sarcomas, 4 lymphomas, and 1 epidermoid carcinoma, have been reported in the Western literature. Soft tissue sarcomas occurred in 31 and bone sarcomas in 10 cases. Malignant fibrous histiocytoma was the most common in 20 (65%) of all soft tissue sarcomas. The patients with malignant tumors had been operated on more often for secondary osteoarthritis and had more local complications than those in ordinary total hip arthroplasty series. Primary osteoarthritis was the indication in 63% and secondary osteoarthritis in 37% of the 38 reported cases. Tumor developed after 8 (17%) revisions. Deep infection complicated 4 (9%) of the cases. Four cases (9%) were preceded by a precondition for cancer, 2 postradiation necroses of the femoral head, 1 chronic sinus, and 1 Mafucci syndrome. Mean age of the patients at the time of first implantation was 59 years (range, 24-79 years). The mean latent period was 6 years (range, 0.5-20 years) from the first operation. Longer latency period did not correlate positively with the cancer risk. Sarcomas were highly aggressive. Of the 31 reported patients, 24 (77%) died within 1 year after the diagnosis. The number of reported sarcoma cases is low considering the total population behind the cases. In addition, one observed local sarcoma from Nordic cohorts was less than expected. Chronic, particle-induced inflammation around the prosthesis does not seem to increase the risk for carcinogenesis.

The objective of this magnetic resonance imaging study was to evaluate the role of degenerative changes, developmental spinal stenosis, and compression of spinal nerve roots in chronic low back (CLBP) and radicular pain in Finnish conscripts. The degree of degeneration, protrusion, and herniation of the intervertebral discs and stenosis of the nerve root canals was evaluated, and the midsagittal diameter and cross-sectional area of the lumbar vertebrae canal were measured in 108 conscripts with CLBP and 90 asymptomatic controls. The midsagittal diameters at L1-L4 levels were significantly smaller in the patients with CLBP than in the controls. Moreover, degeneration of the L4/5 disc and protrusion or herniation of the L5/S1 disc and stenosis of the nerve root canals at level L5/S1 were more frequent among the CLBP patients. Multifactorial analysis of the magnetic resonance imaging findings provided a total explanatory rate of only 33%. Narrowing of the vertebral canal in the anteroposterior direction was more likely to produce CLBP and radiating pain than intervertebral disc degeneration or narrowing of the intervertebral nerve root canals.

UNLABELLED A clinical, plain radiographic, and magnetic resonance imaging retrospective followup study was done on six patients with postoperative septic L4-L5 lumbar spondylodiscitis to identify the characteristic long-term radiographic findings predicting the clinical outcome. The mean followup was 12 years (range, 9-13 years). Three patients had moderate low-back pain and two were handicapped. One patient had slight peroneal weakness. Flexibility of the lumbar spine was restricted to some extent in all patients. Laminectomy for spinal stenosis (L4-L5) had been done in one patient and reoperation because of recurring disc herniation was done in two patients. Partial or total bone marrow depletion and corresponding enhancement of fat signals in relation to adjacent vertebral bodies, narrowing of the intervertebral disc space, and irregularity or cavitations affecting one or both end plates were long-term findings of magnetic resonance imaging. Plain radiographs and magnetic resonance imaging scans revealed a complete bony fusion in one patient and partial fusion in one patient. In two patients, residual disc protrusion or herniation in relation to the surgically treated disc was evident; three affecting L3-L4 and two affecting L5-S1 disc levels. Septic postoperative lumbar discitis severely hampers clinical recovery after disc operations and results in long-term changes as seen on magnetic resonance imaging scans. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

We investigated the association between cartilage lesion and future symptoms in two groups of subjects with patellofemoral pain syndrome (PFPS). Group A consisted of 31 men (mean age 20.9 years, range 19-32) and group B of 28 consecutive patients (12 men and 16 women; mean age 27.8 years, range 15-50) operated on for PFPS. The mean follow-up time was 3.4 (range 1-7) years in group A and 4.9 (range 1-6) years in group B. At follow-up the subjects in group A with severe cartilage lesion (n = 10) reported more knee symptoms as measured by their Kujala score (mean 75.1, SE 3.6 vs. 88.5, SE 2.4) than those with minor cartilage lesion (n = 21) (age and follow-up time-adjusted P0.01). In group B the subjects with severe cartilage lesion tended to report more knee symptoms according to their Kujala score (mean 71.0, SE 7.0 vs. 86.1, SE 5.9; age, sex and follow-up time-adjusted P = 0.15) and VAS score (mean 51.8, SE 11.8 vs. 12.7, SE 10.4; adjusted P = 0.04) than the subjects without cartilage lesion. Our study shows that among the patients with PFPS, the subjects with severe cartilage lesion of the patella or femoral trochlea reported more subjective symptoms and functional limitations at follow-up than those without or with small cartilage lesion of the patella or femoral trochlea.

For this study, all displaced fatigue fractures of the femoral shaft treated during a 20-year period at a national military hospital were analyzed. Ten previously healthy male recruits sustained displaced femoral shaft fatigue fractures, the incidence being 1.5 per 100,000 person-years in military service. The median age of the patients was 19 years (range, 18-20 years). None had any previous fatigue fractures. The median body mass index was normal. Before the fracture displacement, nine recruits experienced thigh or knee pain for 1 to 6 weeks. Six of the 10 fractures were located in the distal third of the diaphysis. Only one fracture occurred in the proximal third. Six fractures showed a noncomminuted, oblique, or oblique-transverse configuration. Five fractures were treated using an intramedullary nail, four fractures with a dynamic compression plate, and one with a dynamic condylar screw-plate. The bone at the site of fracture proved to be abnor mally brittle. In six patients this resulted in addi tional comminution intraoperatively. Two reop erations were necessary to exchange a nail and screw because of technical faults. The medial time to solid bony union was 3.5 months (range 3-5 months). The recruits returned to light duty military service 6 weeks postoperatively, on the average. Two were exempted from military ser vice for 2 years. Displacement is a rare, highly un desirable consequence of fatigue osteopathy of thi femoral shaft among young recruits during basi military training. Preventive methods should fo cus on early, effective detection of developing fa tigue fractures to avoid a displaced fracture, witl subsequent prolonged morbidity and possibly complications. Gentle handling of the bone dur ing the fracture fixation procedure is imperativi because of the extraordinary brittleness of thi fracture fragments.

3 Nordic cohorts of total hip (THA) and total knee arthroplasty (TKA) in patients operated on for primary osteoarthrosis during 1967-1995 were partly adapted and combined for meta-analysis. THA was performed in 49,000 patients and TKA in 24,000 totaling 497,000 person years. The mean and maximum follow-up times were 6.8 and 30 years, respectively. Standardized incidence ratios (SIRs) with 95% confidence intervals (95% CI) were calculated for the observed and expected number of cancers. The expected numbers were based on national incidence rates. The overall SIRs as well as the site-specific ones were similar in the THA and TKA patients. The observed number of cancers at all sites was 7,639 and the expected one was 8,202 (SIR 0.93, 95% CI 0.91-0.95). The SIRs for lung cancer (0.69, 0.64-0.75) and laryngeal cancer (0.64, 0.44-0.92) were reduced. The incidence was also low for cancers of the stomach (SIR 0.76, 0.67-0.84), colon (SIR 0.86, 0.79-0.93) and rectum (SIR 0.89, 0.80-0.98). Among TKA patients, the only increases in SIRs were seen in cancers of the endometrium (SIR 1.36, 1.05-1.74), prostate (SIR 1.19, 1.02-1.38) and, among both THA and TKA patients, in skin melanoma (combined SIR 1.21, 1.03-1.41).

3 Nordic cohorts of total hip (THA) and total knee arthroplasty (TKA) in patients operated on for primary osteoarthrosis during 1967–1995 were partly adapted and combined for meta-analysis. THA was...

Based on the nationwide registration of the total hip arthroplasties (THAs) in Finland since 1980, a cohort of 24,638 patients with primary THA was gathered and followed for causes of death until December 31, 1996. The causes of death were divided into 20 main categories according to the classification of diseases ICD-10. The number of person-years was 153,410, and the mean length of follow-up of a person was 6.2 years. During the follow-up, 4,626 patients died; the expected number was 6,746. The standardized mortality ratio (SMR) was 0.69 (95% confidence interval; 0.67-0.70), without any difference between men and women. The total risk increased during the follow-up, with the highest being 0.84 (95% confidence interval, 0.81-0.87). Among the ICD categories, there were significantly low SMRs for cancers (0.54), accidents (0.74), cardiovascular diseases (0.70), and respiratory diseases (0.46). Among the diseases, there was a constant and significant decline of the SMR for dementia and Alzheimer's disease (0.50), diabetes (0.40), myocardial infarction (0.73), hypertension (0.68), other ischemic diseases (0.70), other heart diseases (0.57), and cerebrovascular diseases (0.70). The explanation for the decreased SMRs seems to be attributed to factors other than the THA per se, such as preoperative patient selection, more active lifestyle after THA, and possibly the use of anti-inflammatory drugs.

We studied the influence of bilaterality and interoperative time on survivorship of the hip prosthesis. The material consisted of 45,000 (3,153 bilateral) total hip arthroplasties and 38,000 patients operated on for primary osteoarthrosis, using data from the Finnish Endoprosthesis Register between 1980 and 1999. Cox regression analysis showed that male sex, young age, uncemented prosthesis and time of surgery (first 10-year period) were significant risk factors for aseptic loosening. We found no difference between the survivorship of the first bilateral and that of unilaterals, but second bilaterals survived better than the unilaterals. Bilateral prostheses survived better when the second prosthesis was implanted during the first postoperative year. The risk of loosening of a bilateral prosthesis increased when the second prosthesis was implanted a few years later. Survivorship of bilateral prosthesesin a 1-stage bilateral operation was about the same as in those operated on within the first postoperative year. Better survivorship of the second bilateral can cause bias in per hip survivorship analyses. In bilateral cases, the second hip should be operated on as soon as possible or be considered for a 1-stage bilateral procedure.

Background and purpose Metal-on-metal hip implants have been widely used, especially in the USA, Australia, England and Wales, and Finland. We assessed risk of death and updated data on the risk of cancer related to metal-on-metal hip replacements. Patients and methods A cohort of 10,728 metal-on-metal hip replacement patients and a reference cohort of 18,235 conventional total hip replacement patients were extracted from the Finnish Arthroplasty Register for the years 2001–2010. Data on incident cancer cases and causes of death until 2011 were obtained from the Finnish Cancer Registry and Statistics Finland. The relative risk of cancer and death were expressed as standardized incidence ratio (SIR) and standardized mortality ratio (SMR). SIR/SIR ratios and SMR/SMR ratios, and Poisson regression were used to compare the cancer risk and the risk of death between cohorts. Results The overall risk of cancer in the metal-on-metal cohort was not higher than that in the non-metal-on-metal cohort (RR = 0.91, 95% CI: 0.82–1.02). The risk of soft-tissue sarcoma and basalioma in the metal-on-metal cohort was higher than in the non-metal-on-metal cohort (SIR/SIR ratio = 2.6, CI: 1.02–6.4 for soft-tissue sarcoma; SIR/SIR ratio = 1.3, CI: 1.1–1.5 for basalioma). The overall risk of death in the metal-on-metal cohort was less than that in the non-metal-on-metal cohort (RR = 0.78, CI: 0.69–0.88). Interpretation The overall risk of cancer or risk of death because of cancer is not increased after metal-on-metal hip replacement. The well-patient effect and selection bias contribute substantially to the findings concerning mortality. Arthrocobaltism does not increase mortality in patients with metal-on-metal hip implants in the short term. However, metal-on-metal hip implants should not be considered safe until data with longer follow-up time are available.

Background and purpose — Metal-on-metal hip implants have been widely used, especially in the USA, Australia, England and Wales, and Finland. We assessed risk of death and updated data on the risk of cancer related to metal-on-metal hip replacements. Patients and methods — A cohort of 10,728 metal-on-metal hip replacement patients and a reference cohort of 18,235 conventional total hip replacement patients were extracted from the Finnish Arthroplasty Register for the years 2001–2010. Data on incident cancer cases and causes of death until 2011 were obtained from the Finnish Cancer Registry and Statistics Finland. The relative risk of cancer and death were expressed as standardized incidence ratio (SIR) and standardized mortality ratio (SMR). SIR/SIR ratios and SMR/SMR ratios, and Poisson regression were used to compare the cancer risk and the risk of death between cohorts. Results — The overall risk of cancer in the metal-on-metal cohort was not higher than that in the non-metal-on-metal cohort (RR = 0.91, 95% CI: 0.82–1.02). The risk of soft-tissue sarcoma and basalioma in the metal-on-metal cohort was higher than in the non-metal-on-metal cohort (SIR/SIR ratio = 2.6, CI: 1.02–6.4 for soft-tissue sarcoma; SIR/SIR ratio = 1.3, CI: 1.1–1.5 for basalioma). The overall risk of death in the metal-on-metal cohort was less than that in the non-metal-on-metal cohort (RR = 0.78, CI: 0.69–0.88). Interpretation — The overall risk of cancer or risk of death because of cancer is not increased after metal-on-metal hip replacement. The well-patient effect and selection bias contribute substantially to the findings concerning mortality. Arthrocobaltism does not increase mortality in patients with metal-on-metal hip implants in the short term. However, metal-on-metal hip implants should not be considered safe until data with longer follow-up time are available. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited.

The performance of 245 male conscripts with chronic low back pain (CLBP) during military service was compared with their pre-conscription performance and with that of 126 age-matched male controls without low back pain (LBP). The frequency of LBP in the conscripts with CLBP increased significantly during their service period compared to risk before service (odds ratio, 10.35; 95% confidence interval, 3.61-29.52). The same factors that induced LBP before entering service, mainly lifting and carrying, also caused LBP during military service. Of the conscripts with CLBP, 120 had experienced an accidental back injury and 125 had injured their backs during lifting or carrying before entering service. During service, back problems were caused by accidents in 88 cases and by lifting or carrying in 157 cases. The frequency of LBP injuries, measured as the need for medical consultation or treatment, increased 2.4-fold (95% confidence interval, 1.41-4.10) during the term of service. Conscripts with CLBP served significantly more frequently as ordinary soldiers than the controls. There was no difference in participation in leisure time or competitive sports activities between the two groups. The future expectations of the CLBP conscripts were pessimistic: only one-fifth believed in complete recovery, and two-fifths thought that they would need substantial outside help in the future.

Nationwide, computer-based reporting of all arthroplasties performed in Finland was started in January 1980. Using data from these records, a cohort of 31,651 polyethylene-on-metal total hip arthroplasty (THA) patients was followed up for cancer, using Finnish Cancer Registry data, from 1980 to 1995. During follow-up, 2,367 cancers were observed. There were statistically significantly fewer cancers among the THA patients (standardized incidence ratio [SIR], 0.90; 95% confidence interval [CI], 0.87-0.93). SIRs for cancers of the lung (0.69) and stomach (0.77) were significantly below unity. There was no significantly increased risk at any site. The SIR for cancer overall in male THA patients was below unity during the first 3 years after THA but returned to unity thereafter. The low SIR among men during the first 3 years was largely because the lung cancer SIR was 0.47 (95% CI, 0.35-0.62). In women, the SIR remained around 0.93 throughout follow-up. The SIR for stomach cancer was below unity only in women (SIR, 0.67; 95% CI, 0.51-0.86). For cancer of the urinary bladder, the SIR during the first 3 years after THA was below unity but later slightly above it (SIR, 1.24 in relation to > or =3 years of follow-up; 95% CI, 0.99-1.52). For myeloma and leukemia, SIRs were greater than unity only for THA patients followed up for 3 to 9 years. The study findings, in contrast to previously reported findings, do not indicate that there is any increased risk of hematopoietic cancers after THA using polyethylene-on-metal prostheses. SIRs relating to soft tissue cancers and bone sarcomas did not differ significantly from unity. No sarcoma was observed at the site of a prosthesis. THA seems to play no major role in cancer causation.

A nationwide, computer-based survey of all total joint arthroplasties performed in Finland has been carried out since January 1980. From these records, a cohort of 9,444 patients, with 51,756 person-years, after primary operation with a total polyethylene-on-metal knee arthroplasty (TKA) was followed up for cancer through the Finnish Cancer Register up to December 31, 1996. During the follow-up, 706 cancers were observed. The expected number, based on national rates, was 719; therefore, the standardized incidence ratio (SIR) for all cancers was 0.98. The SIRs for non-Hodgkin's lymphoma (1.40), Hodgkin's disease (1.24) and multiple myeloma (1.54) were increased, but only that of non-Hodgkin's lymphoma was statistically significant 3-10 years after the operation. The numbers of observed cases of prostate cancer exceeded that of expected, with a SIR value of 1.49. A low SIR of lung cancer was observed among men, especially during the first 3 years (0.61), but not in women. The SIR for colon cancer was below unity in women only (SIR 0.70). The SIR for cancer of the urinary organs was close to unity (0.97). SIR relating to soft tissue and bone cancer did not differ significantly from unity, and none of the 6 sarcomas was observed at the site of a prosthesis. The overall cancer risk after TKA done for primary osteoarthrosis seems not to be increased. The increases in lymphoma and prostate cancer risk, however, are observations that could be related to TKA and justify further follow-up of the cohort.

The causes of death in 1,018 patients operated on for primary osteoarthrosis with cemented total hip arthroplasty (THA) were compared with those of age- and sex-matched orthopaedic control patients and those of the general population in Finland. The mean follow-up period was 12 years for the THA patients and 11 years for the control patients. During the first 4 years after surgery, the mortality of the THA patients from circulatory diseases was significantly increased compared with that of the orthopaedic control patients; the number of deaths in patients with THA was 34 compared with 17 for orthopaedic control patients, the relative risk being 2.00 (95% confidence interval, 1.13–3.54). During the 10-year period after the surgery, the relative risk of death of the THA patients compared with the orthopaedic control patients was 1.50 for death from circulatory diseases (95% confidence intervals, 1.11–2.00), 0.42 for accidental death (95% confidence interval, 0.55–1.08), 0.74 for death from cancer, and 0.77 for death from other causes. The observed numbers of deaths from circulatory diseases or by accidents for patients with THA during a postoperative time frame of 5 to 23 years did not differ from the numbers expected for an age- and sex-matched subgroup of the Finnish population. The number of deaths from cancer was less than expected ( P = .046).

Findings of an early arthroscopy performed in 108 consecutive hemarthrotic and clinically stable knees were analyzed. The patients were young conscripts, the mean age being 19.9 years. Fifty-seven of the knees were injured during military training, 36 in different sports activities, 9 at falls, and 6 in motorbike accidents. The lesions were divided into "primary" (lesions needing operative treatment or the supposed most common lesions in incidence) and "secondary" (other lesions). An average of 1.6 lesions were observed per knee. Dislocation of the patella was the most common diagnosis in 38 (35%) cases. Dislocation of the patella was associated with military exercise (p < 0.001). Lesions of the anterior cruciate ligament (ACL) were observed in 37 (34%) cases. ACL ruptures were related to sport activities (p < 0.0001).

BACKGROUND: Surgical treatment of Osgood-Schlatter disease is occasionally warranted, but its long-term prognosis remains poorly investigated. We studied the rate of occurrence of surgical treatment of unresolved Osgood-Schlatter disease as well as the clinical course, radiographic characteristics, and long-term outcomes after that treatment in a large population of military recruits. METHODS: During a thirteen-year period, 178 consecutive recruits underwent surgery for unresolved Osgood-Schlatter disease, and 107 of them (117 knees) who met the inclusion criteria participated in a follow-up examination. We obtained data from the original medical records and radiographs as well as follow-up information from physical and radiographic examinations, interviews, and questionnaires to determine functional outcomes. RESULTS: The rate of occurrence of surgically treated unresolved Osgood-Schlatter disease was forty-two per 100,000 military recruits. The median age at the onset of symptoms was fifteen years. After a median duration of follow-up of ten years after the surgery, ninety-three patients (87%) reported no restrictions in everyday activities or at work and eighty (75%) had returned to their preoperative level of sports activity. The median modified Kujala score was 95 points, and the median visual analog score for pain was 7 mm. Forty-one patients (38%) reported a complete absence of pain when kneeling. Six patients had experienced minor postoperative complications, and two had undergone a reoperation for the treatment of the Osgood-Schlatter disease. After resection, the mean tibial tuberosity thickness decreased by 47%. The mean Insall-Salvati index was 1.0 preoperatively and 1.09 postoperatively (p = 0.003), and the corresponding mean Blackburne-Peel indexes were 0.85 and 0.95 (p = 0.003). With the numbers studied, the symptom duration, surgical methods, and radiographic indexes were not found to have an effect on the outcome of surgery. CONCLUSIONS: In the great majority of young adults, the functional outcome of surgical treatment of unresolved Osgood-Schlatter disease is excellent or good, the residual pain intensity is low, and postoperative complications or subsequent reoperations are rare. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. ORIGINAL ABSTRACT CITATION: “Long-Term Outcome After Surgical Treatment of Unresolved Osgood-Schlatter Disease in Young Men” (2009;91:2350-8).

Background: Some have recommended surgical treatment of Grade-III lateral ligament injuries in very active individuals with high functional demands on the ankle. The purpose of this study was to establish whether surgery provides better long-term results than functional treatment for acute ruptures of the lateral ligaments of the ankle. Methods: Physically active Finnish men (mean age, 20.4 years) with an acute Grade-III lateral ligament rupture of the ankle were randomly allocated to surgical (n = 25) or functional (n = 26) treatment. Ligament injury was confirmed with stress radiographs. Surgical treatment comprised suture repair of the injured ligament(s) within the first week after injury. A below-the-knee plaster cast was worn for six weeks with full weight-bearing. Functional treatment consisted of the use of an Aircast ankle brace for three weeks. The main outcome measures included final follow-up examinations, calculation of an ankle score, stress radiographs, and magnetic resonance imaging scans. Results: Fifteen (60%) of twenty-five surgically treated patients and eighteen (69%) of twenty-six functionally treated patients returned for long-term follow-up (mean duration, fourteen years). All patients in both groups had recovered their preinjury activity level and reported that they could walk and run normally. The prevalence of reinjury was one of fifteen in the surgical group and seven of eighteen in the functional treatment group (risk difference: 32%; 95% confidence interval: 6% to 58%). The mean ankle score did not differ significantly between the groups (mean difference: 8.3 points; 95% confidence interval: –0.03 to 16.6 points). Stress radiographs revealed no difference between groups with regard to the mean anterior drawer (–1 mm in the surgical group and 0 mm in the functional treatment group; mean difference: 0.7 mm; 95% confidence interval: –1.4 to 2.7 mm) or mean tilt angle (0° in both groups; mean difference: 0.1°; 95% confidence interval: –3.2° to 3.5°). Grade-II osteoarthritis was observed on magnetic resonance images of four of the fifteen surgically treated patients and in none of the eighteen functionally treated patients (risk difference: 27%; 95% confidence interval: 4% to 49%). Conclusions: These findings indicate that, in terms of recovery of the preinjury activity level, the long-term results of surgical treatment of acute lateral ligament rupture of the ankle correspond with those of functional treatment. Although surgery appeared to decrease the prevalence of reinjury of the lateral ligaments, there may be an increased risk for the subsequent development of osteoarthritis. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Background and purpose Wear debris from conventional total hip arthroplasty (THA) induces chromosomal aberrations and DNA damage, which may promote cancerogenesis. A long latent period is required for solid tumors. We therefore re-analyzed a large THA cohort for cancer. Patients and methods We updated a cohort of 24,636 patients with primary osteoarthritis and metal-on-polyethylene THA who had been entered in the Finnish Arthroplasty Register between 1980 and 1995, and linked it to the Finnish Cancer Registry for cancer risk assessment up to 2005. The mean follow-up time was 13 years. The numbers of cancer cases observed were compared with expected rates based on incidence in the general population. Results The standardized incidence ratio (SIR) for the whole follow-up period was 0.95 (95% confidence interval (CI): 0.92–0.97). After 10 years of follow-up, the SIR was equal to that in the normal population (SIR = 0.98, 95% CI: 0.94–1.03). Incidence of lung cancer was low throughout the follow-up time and that of prostate cancer was slightly elevated. The incidence rates for all other forms of cancer did not deviate significantly from those in the normal population. Interpretation We found no increased cancer risk in patients with conventional THA after an average of 13 years and up to 25 years of follow-up.

The clinical role of patellofemoral (PF) osteoarthrosis (OA) in the outcome after PF stabilizing surgery is poorly understood. The study hypothesis was that PF cartilage lesions and OA are associated with a poor long-term outcome after PF stabilizing surgery. The study cohort included thirty-seven patients who underwent PF stabilizing surgery by traditional nonanatomic procedures and were evaluated a minimum of 10 years (range 10–21) after surgery. PF OA was assessed by magnetic resonance (MR) images and plain radiographs obtained at follow-up. Median patient age at follow-up was 33 years (29–43). At the final follow-up, PF full-thickness cartilage lesions were observed on MR images in 29 (78%) patients. Only 46% of the patients reported satisfaction at follow-up, and dissatisfaction was associated with PF OA (full-thickness articular cartilage loss on MR images; P = 0.022). Especially high incidence, 89%, of medial patellar facet cartilage lesions were found among the patients dissatisfied with the result (16/18 patients) (n.s.). Eight (22%) of the 37 patients reported recurrent patellar instability episodes at follow-up. Median Kujala score was 83 points (range 55–98). Patellofemoral OA is a significant long-term risk of nonanatomic surgery for patellar instability and has a greater impact on subjective outcome than residual instability more than 10 years after surgery.

Background All patients with total hip arthroplasty (THA), especially those with metal-on-metal (MM) THA, are exposed to metallic particles and ions, which may cause total or site-specific mortality. We analyzed the causes of total and site-specific mortality among a cohort of patients with MM and with metal-on-polyethylene (MP) THA after a long follow-up time. Methods Standardized mortality ratios (SMR) of total and site-specific causes of death were calculated for 579 patients with MM (McKee-Farrar) and 1585 patients with MP (Brunswik, Lubinus) THA for primary osteoarthritis. Results Mean follow-up time was 17.9 years for patients with MM and 16.7 years for patients with MP. Overall SMR was 0.95 for the MM cohort and 0.90 for the MP cohort, as compared to the normal population. Both cohorts showed significantly decreased mortality for the first decade postoperatively, equal mortality over the next 10 years, and significantly increased mortality after 20 years. Patients with MM THA had higher cancer mortality (SMR 1.01) than those with MP THA (SMR 0.66) during the first 20 years postoperatively, but not thereafter. Conclusion Both MM and MP prostheses are safe based on total and site-specific mortality of recipients during the first 20 postoperative years in comparison with the general population.

Background The clinical relevance of medial patellofemoral ligament (MPFL) injury location in primary patellar dislocation has not been studied. Hypothesis Prognosis after primary traumatic patellar dislocation may vary by MPFL injury location. Study Design Cohort study; Level of evidence, 3. Methods The initial magnetic resonance imaging (MRI) findings in 53 patients with identical nonoperative management were retrospectively analyzed for medial restraint injuries. The MPFL injury sites were classified as follows: femoral, midsubstance, and patellar. Magnetic resonance imaging was used to assess initial and control articular cartilage lesions in the patellofemoral joint. After a mean follow-up of 7 years, 42 patients were evaluated for redislocations, subjective symptoms, and functional limitations. Results Based on the initial MRIs, MPFL rupture was classified as femoral in 35 patients, midsubstance in 11, and patellar in 7. At follow-up, 15 patients reported an unstable patella (13 femoral, 1 patellar, 1 midsubstance; P =. 01) and 9 reported patellar redislocations (8 femoral, 1 midsubstance; P =. 05). The proportion of patients who regained their preinjury activity level was significantly smaller among those with femoral MPFL injury than among those with midsubstance or patellar MPFL injury (P =. 05). The median Kujala score was as follows: 90 for femoral, 91 for patellar, and 96 for midsubstance (P =. 76). Control MRI showed full-thickness patellofemoral cartilage lesions in 50% of the patients, unrelated to MPFL injury location. Conclusion An MPFL avulsion at the femoral attachment in primary traumatic patellar dislocations predicts subsequent patellar instability. The authors suggest that MPFL injury location be taken into account when planning treatment of primary traumatic patellar dislocation.

Background There is evidence that low back pain (LBP) during young adulthood and military service predicts LBP later in life. The purpose of this study was to investigate the incidence and trends of LBP hospitalisation among Finnish military conscripts. Methods All male conscripts performing their compulsory military service during 1990–2002 were included in the study population. Altogether 387,070 military conscripts were followed throughout their six-to-twelve-month service period. Data on LBP hospitalisations were obtained from the National Hospital Discharge Register. Results Altogether 7,240 LBP hospitalisations were identified among 5,061 (1.3%) male conscripts during the study period. The event-based incidence of LBP hospitalisation was 27.0 (95% confidence interval (CI): 25.7–28.2). In most cases, the diagnosis was unspecified LBP (n = 5,141, 71%) followed by lumbar disc disorders (n = 2,069, 29%). Hospitalisation incidence due to unspecified LBP was 19.1 per 1,000 person-years (95% CI: 18.3 to 20.4), and 7.8 per 1,000 person-years (95% CI: 6.7 to 8.3) due to lumbar disc disorders. The incidence of unspecified LBP remained unaltered, while hospitalisation due to lumbar disc disorders declined from 1993 onwards. Conclusion Although conscripts accepted into military training pass physician-performed examinations as healthy, young adults, LBP hospitalisation causes significant morbidity during military service.

Patellar dislocations are associated with injuries to the medial patellofemoral ligament (MPFL). Several techniques for MPFL reconstruction have been recently published with some disadvantages involved, including large skin incisions and donor site morbidity. Arthroscopic stabilizing techniques carry the potential of inadequate restoration of MPFL function. We present a minimally invasive technique for MPFL reconstruction using adductor magnus tendon autograft. This technique is easily performed, safe, and provides a stabilizing effect equal to current MPFL reconstructions. Skin incision of only 3-4 cm is located at the level of the proximal half of the patella. After identifying the distal insertion of the adductor magnus tendon, a tendon harvester is introduced to harvest the medial two-thirds of the tendon, while the distal insertion is left intact. The adductor magnus tendon is cut at 12-14 cm from its distal insertion and transferred into the patellar medial margin. Two suture anchors are inserted through the same incision at the superomedial aspect of the patella in the anatomic MPFL origin. The graft is tightened at 30 degrees knee flexion. Aftercare includes 4 weeks of brace treatment with restricted range of motion.

Purpose: The purpose of this study was to investigate incidence, nature, and risk factors of primary traumatic patellar dislocations. Methods: We identified acute first-time traumatic patellar dislocations from a national hospital discharge register. Patients with previous patellar dislocations, subluxations, or knee traumas were excluded. The sample consisted of 128,714 Finnish male conscripts (median age 20). Background risk factor data were obtained from a Finnish conscript service database. The dislocators were observed during their service period for a short-term outcome. Results: From the 128,714 male conscripts, 278 had patellar dislocations, and 72 were classified as having sustained first-time traumatic patellar dislocations. The 128,436 nondislocators served as a control group. The incidence of acute traumatic primary patellar dislocations among male conscripts was 77.4 (95% CI: 61.1-96.8) per 100,000 persons per year. The male patients with traumatic primary patellar dislocations were taller (P = 0.03) and weighed more (P = 0.02) than the controls. Hemarthrosis was present in all patients, and when MRI or open surgery was performed, medial retinacular disruption and medial patellofemoral ligament (MPFL) injury were identified. Patients' return to military service was unrelated to the choice of treatment. Conclusion: Primary patellar dislocation is not a negligible cause of morbidity among young male adults. It can be concluded that hemarthrosis and MPFL rupture are the definite signs of an acute traumatic primary patellar dislocation. Height and weight were significant risk factors, whereas poor physical performance was not associated with primary patellar dislocation.

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.

All patients with total hip arthroplasty (THA) are exposed to soluble or particulate forms of Co and Cr. Adverse effects of these wear products are not known. Data from Nordic registries is used to estimate adverse effects on a large scale, based mostly on metal-on-polyethylene bearings. Cancer incidence was in line with the general population when the patients were operated on for all indications and significantly decreased when the indication was primary osteoarthritis. Stomach cancer and colorectal cancers were significantly reduced and prostate cancer and skin melanoma significantly increased. There was no significant excess of cancer in target organs, i.e. liver, kidney, or haematopoietic cancers. THA patients had reduced mortality and extended life expectancy compared with standard Nordic populations. All-site cancer incidence of the first-generation metal-on-metal McKee-Farrar patients operated on for primary osteoarthritis was in line with the general population after follow-up for up to 28 years. General mortality of these patients was also reduced and they also had an extended life expectancy. Temporary increases in haematopoietic cancers at different follow-up periods were seen in some cohorts. This malignancy deserves a special record linkage monitoring while large numbers of young patients are provided with the second generation of metal-on-metal prostheses.

Background and Aims:This study was undertaken to evaluate the relationship between overweight and severity of arthroscopically confirmed primary cartilage lesions of the knee.Material and Methods:The hospital records of 88 young male adults (98 knees), who underwent arthroscopy of the knee and were diagnosed of primary cartilage lesion during 1997–98, were reviewed. The depth of the lesions was graded according to Beguin and Locker classification.Results:73.5 % of the lesions were patellar and 12.0 % in the medial condyle of the femur. 74.5 % of the patients had superficial (grade I—II) and 25.5 % deep (grade III—IV) lesions. Patients with deep lesions had a significantly higher body mass index (BMI 25.3 vs. 22.9, p < 0.001) and they were older (20.8 vs. 19.7 years, p = 0.023) than other patients. Similarly, patients with overweight (BMI ≥ 25.0) had significantly more often deep lesions than other patients (50 % vs. 10.4 %, p < 0.001).Conclusions:These results suggest, that overweight may predispose young patients to more severe cartilage lesions independent of other etiologic factors, and support the hypothesis of the cumulative effect of overweight on cartilage injuries during early adult life.

The aim of this study was to describe the MRI findings and clinical observations in a fatigue stress fracture of the sacrum. In this retrospective study, 380 conscripts (53 women, 327 men; age range 18–29 years, mean age 20.7 years) who suffered from stress-related hip pain were studied with MRI of the pelvis. The findings of MRI were evaluated with regard to stress fracture of the sacrum. Thirty-one (8%) patients had MRI changes in signal intensity of the cranial part of the sacrum, extending to the first and second sacral foramina. The MRI changes in signal intensity were intermediate on T1-weighted images, and high on short tau inversion recovery or T2-weighted fat-suppressed images. A linear signal void fracture line was also seen. Multiple stress injuries to the pelvic bones were also seen in 7 of 31 (23%) patients. Five patients (16%) had bilateral sacral stress fracture. Fatigue sacral stress fractures appeared more commonly in women than in men (p

We studied the influence of bilaterality and interoperative time on survivorship of the hip prosthesis. The material consisted of 45,000 (3,153 bilateral) total hip arthroplasties and 38,000 patients operated on for primary osteoarthrosis, using data from the Finnish Endoprosthesis Register between 1980 and 1999. Cox regression analysis showed that male sex, young age, uncemented prosthesis and time of surgery (first 10-year period) were significant risk factors for aseptic loosening. We found no difference between the survivorship of the first bilateral and that of unilaterals, but second bilaterals survived better than the unilaterals. Bilateral prostheses survived better when the second prosthesis was implanted during the first postoperative year. The risk of loosening of a bilateral prosthesis increased when the second prosthesis was implanted a few years later. Survivorship of bilateral prosthesesin a 1-stage bilateral operation was about the same as in those operated on within the first postoperative year. Better survivorship of the second bilateral can cause bias in per hip survivorship analyses. In bilateral cases, the second hip should be operated on as soon as possible or be considered for a 1-stage bilateral procedure.

Between 1990 and 1996, 119 Finnish male conscripts underwent operative treatment for patellar dislocation. There were 68 conscripts (58%) with primary and 51 conscripts (42%) with recurrent patellar dislocation. Sixty-five (55%) dislocations occurred during military service, 40 (34%) occurred during sports activities, and 14 (11%) occurred during leisure time. The most common cause of injury was military training at battle exercises (n = 30). The typical injury mechanism was knee valgus rotation on fixed foot and tibia (97 conscripts, 82%). Surgical procedures performed were open in 75 conscripts (63%) and arthroscopically assisted in 44 conscripts (37%). Twenty-three (19%) redislocations occurred during follow-up (mean, 6 years; range, 3-9 years). The subjective outcome of treatment was excellent in 23 (19%), good in 42 (35%), moderate in 44 (37%), and poor in 10 (9%) conscripts. The most common residual complaint was patellofemoral pain (25 conscripts, 21%). Only 42 (35%) conscripts were able to finish their military service normally; fitness classification was decreased in 16 conscripts (13%), and 61 (52%) were temporarily exempted from military service (class E). The results of operative treatment did not differ significantly in conscripts with primary and recurrent dislocation, except for the time of first recurrence, which was significantly longer in conscripts with primary than with recurrent dislocation (27 versus 9 months). Patellar dislocation is the most common form of severe knee injury among conscripts and significantly hampers military service. Operative treatment yields only satisfactory results. Preventive measurements should be considered. A suggested algorithm for the treatment and classification of acute and recurrent patellar dislocation among military conscripts is presented.

Based on the nationwide registration of the total hip arthroplasties (THAs) in Finland since 1980, a cohort of 24,638 patients with primary THA was gathered and followed for causes of death until December 31, 1996. The causes of death were divided into 20 main categories according to the classification of diseases ICD-10. The number of person-years was 153,410, and the mean length of follow-up of a person was 6.2 years. During the follow-up, 4,626 patients died; the expected number was 6,746. The standardized mortality ratio (SMR) was 0.69 (95% confidence interval; 0.67-0.70), without any difference between men and women. The total risk increased during the follow-up, with the highest being 0.84 (95% confidence interval, 0.81-0.87). Among the ICD categories, there were significantly low SMRs for cancers (0.54), accidents (0.74), cardiovascular diseases (0.70), and respiratory diseases (0.46). Among the diseases, there was a constant and significant decline of the SMR for dementia and Alzheimer's disease (0.50), diabetes (0.40), myocardial infarction (0.73), hypertension (0.68), other ischemic diseases (0.70), other heart diseases (0.57), and cerebrovascular diseases (0.70). The explanation for the decreased SMRs seems to be attributed to factors other than the THA per se, such as preoperative patient selection, more active lifestyle after THA, and possibly the use of anti-inflammatory drugs.

I present 10 cases of spongious bone injury of the femoral head induced by physical stress. All patients were young military recruits who complained of hip pain from weight bearing which had started during physical exertion. Increased uptake in a radionuclide bone scan was regarded as the criterion for stress osteopathy. 7 hips were radiographically normal. In 3 cases a subcortical lateral cystic lesion of the femoral head was observed. MRI was performed in 6 cases. A decreased signal intensity in T1-weighted images in 5 cases and high signals in T2-weighted and IR signals (2 patients) indicated bone marrow edema. A lateral osteophyte of the femoral head developed in 1 case during 8 years' follow-up. After a median of 6 years, 9 patients still had occasional slight hip pain.

The incidence of cancer after metal on metal total hip arthroplasty (McKee-Farrar) and polyethylene on metal total hip arthroplasty (Brunswik, Lubinus) was compared with that of the general population in Finland. The mean followup time for the patients who had metal on metal total hip arthroplasty was 15.7 (9092 person years) and for the patients who had polyethylene on metal total hip arthroplasty it was 12.5 years (19,846 person years). One hundred thirteen malignant cancers were observed in patients who had metal on metal total hip arthroplasty and 212 were observed in patients who had polyethylene on metal total hip arthroplasty. The standardized incidence ratio for all cancers of the metal on metal arthroplasty group was 0.95 (95% confidence limits 0.79-1.13) and that of the polyethylene on metal arthroplasty group was 0.76 (95% confidence limits 0.68-0.86). The risk of total cancer in the patients who had metal on metal total hip arthroplasty was 1.23-fold compared with that of the patients who had polyethylene on metal total hip arthroplasty. Both groups had significantly less lung cancer than the general population: the leukemia incidence in the patients who had metal on metal total hip arthroplasty was slightly increased (observed to experienced 7/3.03, standardized incidence ratio 0.61; 95% confidence limits 0.17-1.56). The leukemia rate of the patients who had metal on metal total hip arthroplasty was 3.77-fold compared with that of the patients who had polyethylene on metal total hip arthroplasty, but this difference was not statistically significant. No sarcomas were observed at the site of the prosthesis. The incidence of the other forms of cancers did not differ significantly from those in the general population. The observed variation in the incidence of different cancers among patients who had total hip arthroplasty compared with the general population suggests that factors other than total hip arthroplasty play a major role in the origin of cancer.

Objective To assess the risk of cancer associated with modern primary metal-on-metal hip replacements. Design Population based study. Setting Nationwide retrospective comparative register. Participants 10 728 patients who underwent metal-on-metal total hip arthroplasty and 18 235 patients who underwent conventional metal-on-polyethylene, ceramic-on-polyethylene, and ceramic-on-ceramic total hip arthroplasty (the non-metal-on-metal cohort) in the Finnish Arthroplasty Register 2001-10. Data on cancer cases up to 2010 for these cohorts were extracted from the Finnish Cancer Registry. Main outcome measures The relative risk of cancer was expressed as the ratio of observed to expected number of cases from the Finnish population—that is, the standardised incidence ratio. The relative risk of cancer in the metal-on-metal cohort compared with the non-metal-on-metal cohort was estimated with analyses of these ratios and Poisson regression. Results The overall risk of cancer in patients with metal-on-metal hip implants was similar to that in the Finnish population (378 observed v 400 expected, standardised incidence ratio 0.95, 95% confidence interval 0.85 to 1.04). The overall risk of cancer in patients with metal-on-metal hip implants was also no higher than in patients who had received non-metal-on-metal hip implants (relative risk 0.92, 0.81 to 1.05). Conclusions Metal-on-metal hip replacements are not associated with an increased overall risk of cancer during a mean follow-up of four years.

The long-term survival of 1018 total hip arthroplasty FHA) patients (237 McKee-Farrar, 449 Brunswik and 332 Lubinus patients) operated on for primary arthrosis was compared with pair-matched controls (i.e., patients operated on for other orthopedic indications) and with a normal population. The 1 0-year survival after surgery for the McKee-Farrar patients was 85 percent, for the Brunswik patients 82 percent, for the Lubinus patients 82 percent and for the orthopedic control patients 84 percent, respectively. The 10-year survival after 65 years of age for the THA patients was 78 percent and for the normal population 73 percent. The long-term life expectancy of our patients with a cemented THA was equal to that of our orthopedic control group and better than the life expectancy of the Finnish population.

[Figure][1] [Introduction][2] Surgical treatment of an acute lateral ligament rupture is occasionally warranted. ![Figure][1] [Step 1: Incision][3] Make a skin incision from the anterior aspect of the fibula and curve it inferiorly and posteriorly. ![Figure][1] ![Figure][1] ![Figure][1] ![Figure][1] [Step 2: Repair][4] Repair the ligaments with absorbable sutures; if there is bone avulsion, pass the sutures through drill holes or use a suture anchor. [Step 3: Closure][5] Close the wound in layers using absorbable sutures. [Step 4: Postoperative Care][6] Cast immobilization for four weeks is followed by orthosis use for two weeks; muscle exercises are initiated on the first postoperative day. [Results][7] In our previous randomized controlled trial comparing surgical and functional treatment of acute ruptures of the lateral ligament complex of the ankle, the mean score on the Performance Test Protocol and Scoring Scale for the Evaluation of Ankle Injuries was 83 ± 11 points in the surgical treatment group and 75 ± 13 points in the functional treatment group (mean difference: 8.3 points; 95% confidence interval: –0.03 to 16.6 points). [What to Watch For][8] [Indications][9] [Contraindications][10] [Pitfalls & Challenges][11] ![Figure][1] [Introduction][2] Surgical treatment of an acute lateral ligament rupture is occasionally warranted. ![Figure][1] [Step 1: Incision][3] Make a skin incision from the anterior aspect of the fibula and curve it inferiorly and posteriorly. ![Figure][1] ![Figure][1] ![Figure][1] ![Figure][1] [Step 2: Repair][4] Repair the ligaments with absorbable sutures; if there is bone avulsion, pass the sutures through drill holes or use a suture anchor. [Step 3: Closure][5] Close the wound in layers using absorbable sutures. [Step 4: Postoperative Care][6] Cast immobilization for four weeks is followed by orthosis use for two weeks; muscle exercises are initiated on the first postoperative day. [Results][7] In our previous randomized controlled trial comparing surgical and functional treatment of acute ruptures of the lateral ligament complex of the ankle, the mean score on the Performance Test Protocol and Scoring Scale for the Evaluation of Ankle Injuries was 83 ± 11 points in the surgical treatment group and 75 ± 13 points in the functional treatment group (mean difference: 8.3 points; 95% confidence interval: –0.03 to 16.6 points). [What to Watch For][8] [Indications][9] [Contraindications][10] [Pitfalls & Challenges][11] [1]: pending:yes [2]: #sec-8 [3]: #sec-9 [4]: #sec-10 [5]: #sec-11 [6]: #sec-12 [7]: #sec-13 [8]: #sec-14 [9]: #sec-15 [10]: #sec-16 [11]: #sec-17

Cardiovascular functional stability was studied in 17 young men (20-year-old conscripts) with the symptoms of primary fibromyalgia (PF). They were compared to 20 medical students of the same age. The subjects underwent an orthostatic test, deep breathing test, Valsalva maneuver, and a handgrip test. They were evaluated by an autoanamnestic questionnaire on vegetative symptoms and laboratory tests on blood chemistry. The heart rate of the PF group after 8 min of active standing was 32 +/- 15 beats/min greater than at supine rest. The corresponding figure for the controls was 23 +/- 7 beats/min (p = 0.001). Twelve conscripts with PF (71%) presented sympathicotonic cardiovascular reaction on the orthostatic test (p < 0.001). Four of these sympathicotonic conscripts and two other conscripts (total 35%) had an abnormal high index of dystonic symptoms (p = 0.01). The results suggest that young men with symptoms of PF have not only cardiovascular dystonic symptoms but also increased sympathetic nervous reactivity of the cardiovascular system.

Three cases of displaced stress fracture of the femoral shaft are reported. All patients were young conscripts. Before displacement, the patients had suffered from knee and distal femoral pains for 2-6 weeks. All fractures were located at the border of the middle and distal third of the femoral shaft and had a short oblique form. Plating was performed in two and intramedullary nailing in one case. A fast bony union into a good position was achieved in all cases. Scintigraphy is indicated for an early diagnosis, which enables conservative treatment and prevention of the fracture displacement.

To the Editor: I read with interest the paper by Sillanpaa et al. [1] entitled “Ligament Reconstruction Versus Distal Realignment for Patellar Dislocation” published in the June 2008 issue. I congratulate the authors on their study, for the long-term followup and for the comparative study with distal realignment. However, I ask for clarification of two issues. First, what are the indications for medial patellofemoral ligament reconstruction? Do you perform this surgical technique in all patients with patellar recurrent dislocation? Soft tissue abnormalities, such as lateral retinacular tightness, and some bony geometric knee parameters, such as the tibial tubercle-trochlear groove distance, patella alta, and trochlea dysplasia, can cause patellofemoral instability. Do you combine additional surgical procedures, such as a distal realignment and/or lateral retinacular release, when you find an abnormal Q angle (> 10°), or a great tibial tubercle-trochlear groove distance (> 20 mm), or a flattened trochlea? Trochlea dysplasia is thought to lead to excessive load on the medial patellofemoral ligament reconstruction, and tibial tuberosity transfer would, in theory, reduce the load to the reconstruction. Second, I believe a surgical technique can prevent degenerative changes when it improves patellofemoral tracking and corrects some abnormal geometric parameters, such as congruence angle or lateral patellofemoral angle. Have you assessed postoperatively by radiographs or MRI whether the ligament reconstruction was able to correct the above-mentioned parameters, in comparison to the contralateral knee?

Thirteen patients with 14 large rotator cuff tears were operated on using carbon fiber to cover the defect. The median follow-up time was 4 years. In 11, 1, and 2 cases the results were respectively excellent or good, fair, and poor. In 2 cases where the carbon fiber was anchored to the major tuberosity, a bone cyst was seen, but it did not influence the result. A carbon fiber tow application combined with Neer's anterior acromioplasty seems useful in the reconstruction of large tears of the rotator cuff.

Cancer incidence in 433 McKee-Farrar total hip replacement patients, operated on between 1967 and 1973, was examined for 5729 person-years, to the end of 1981. The expected number of natural deaths was slightly higher than observed, suggesting some selection of the operated patients. The risk of total cancer incidence did not increase, but the risk for site-specific cancer did because there were no cases of kidney or bladder cancer, or rare forms of cancer. The risk of leukemias and lymphomas increased, and the risk of breast cancer decreased; these results were surprisingly similar to those of a study from New Zealand. This study concluded that patients with total hip prostheses have a cancer morbidity differing from the general population. The role of chrome-cobalt - molybdenum alloy in carcinogenesis requires further investigation.