Harri Pihlajamäki

Complications of plate fixation in fresh displaced midclavicular fractures.

BACKGROUND The role of plate fixation in the management of fresh displaced midclavicular fractures is unsettled. The objective of this study was to evaluate the drawbacks and pitfalls of this treatment method. METHODS We analyzed the complications encountered in 103 consecutive adult patients with severely displaced fresh fractures of the middle third of the clavicle who were treated by open reduction and internal fixation using AO/ASIF plates. These 103 patients accounted for 9.5% of the 1,081 patients with fresh midclavicular fractures seen between 1989 and 1995. The mean age of the 103 patients was 33.4 years (range, 19-62 years). RESULTS Seventy-nine patients had an uneventful recovery, whereas 24 (23%) suffered one or several complications. The major complications included deep infection, plate breakage, nonunion, and refracture after plate removal. The most common of the minor complications was plate loosening resulting in malunion. The infection rate was 7.8%. A total of 14 reoperations were performed because of the complications. Permanent nonunion ensued in two patients. A severely comminuted fracture (relative risk of failure, 5.15) as well as a state of alcohol intoxication on admission (relative risk of failure, 3.12) were identified as markers of increased complication risk. CONCLUSIONS Patient noncompliance with the postoperative regimen could be suspected to have been a major cause of the failures. The high complication rate supports a reserved attitude toward plate fixation of fresh midclavicular fractures. The method should be reserved for patients who have trustworthy personal motives for quick pain relief and functional recovery.

Mortality and cause of death in hip fracture patients aged 65 or older - a population-based study

BackgroundThe high mortality of hip fracture patients is well documented, but sex- and cause-specific mortality after hip fracture has not been extensively studied. The purpose of the present study was to evaluate mortality and cause of death in patients after hip fracture surgery and to compare their mortality and cause of death to those in the general population.MethodsRecords of 428 consecutive hip fracture patients were collected on a population-basis and data on the general population comprising all Finns 65 years of age or older were collected on a cohort-basis. Cause of death was classified as follows: malignant neoplasms, dementia, circulatory disease, respiratory disease, digestive system disease, and other.ResultsMean follow-up was 3.7 years (range 0-9 years). Overall 1-year postoperative mortality was 27.3% and mortality after hip fracture at the end of the follow-up was 79.0%. During the follow-up, age-adjusted mortality after hip fracture surgery was higher in men than in women with hazard ratio (HR) 1.55 and 95% confidence interval (95% CI) 1.21-2.00. Among hip surgery patients, the most common causes of death were circulatory diseases, followed by dementia and Alzheimers disease. After hip fracture, men were more likely than women to die from respiratory disease, malignant neoplasm, and circulatory disease. During the follow-up, all-cause age- and sex-standardized mortality after hip fracture was 3-fold higher than that of the general population and included every cause-of-death category.ConclusionDuring the study period, the risk of mortality in hip fracture patients was 3-fold higher than that in the general population and included every major cause of death.

Association between serum 25(OH)D concentrations and bone stress fractures in Finnish young men.

Low vitamin D level may predict rickets, osteomalacia, or osteoporosis. We examined serum 25(OH)D concentration as a predisposing factor for bone stress fracture in 756 military recruits. The average serum 25(OH)D concentration was significantly lower in the group with fracture, suggesting a relationship between vitamin D and fatigue bone stress fracture.

COMPLICATIONS OF TRANSPEDICULAR LUMBOSACRAL FIXATION FOR NON-TRAUMATIC DISORDERS

We analysed the complications encountered in 102 consecutive patients who had posterolateral lumbosacral fusion performed with transpedicular screw and rod fixation for non-traumatic disorders after a minimum of two years. Of these, 40 had spondylolysis and spondylolisthesis, 42 a degenerative disorder, 14 instability after previous laminectomy and decompression, and six pain after nonunion of previous attempts at spinal fusion without internal fixation. There were 75 multilevel and 27 single-level fusions. There were 76 individual complications in 48 patients, and none in the other 54. The complications seen were screw misplacement, coupling failure of the device, wound infection, nonunion, permanent neural injury, and loosening, bending and breakage of screws. Screw breakage or loosening was more common in patients with multilevel fusions (p < 0.001). Screws of 5 mm diameter should not be used for sacral fixation. Forty-six patients had at least one further operation for one or several complications, including 20 fusion procedures for nonunion. The high incidence of complications is a disadvantage of this technically-demanding method.

Vitamin D supplementation for the prevention of acute respiratory tract infection: a randomized, double-blinded trial among young Finnish men.

Ilkka Laaksi, Juha-Petri Ruohola, Ville Mattila, Anssi Auvinen, Timo Ylikomi, and Harri Pihlajamaki Department of Cell Biology, Medical School, and Department of Epidemiology, Tampere School of Public Health, University of Tampere, and Department of Clinical Chemistry, Tampere University Hospital, Tampere, and Finnish Defence Forces and Research Department, Centre for Military Medicine, Helsinki, Finland

Routine implant removal after fracture surgery: a potentially reducible consumer of hospital resources in trauma units.

OBJECTIVE Assess the workload caused by elective routine removals of internal fracture fixation devices in a large university orthopedic and trauma unit when no premeditated departmental removal policy existed. MATERIALS AND METHODS Data on all operations performed during a 7-year period were retrieved. Routine removals of internal fracture fixation implants were analyzed for demographic data and clinical details. Patients requiring additional procedures to manage the fracture besides simple hardware removal were excluded. Nationwide data were included for comparison. RESULTS A total of 5,095 routine implant removal operations were performed after uneventful fracture union. The mean age of the patients was 42 years. The five most common fracture types were fractures of the ankle, the proximal femur, the tibial shaft, the femoral shaft, and the thoracolumbar spine. In 63% of the procedures, a medium-size or large implant was removed. The mean operation time was 37 minutes. The removals accounted for 29% of all elective operations and for 15% of all operations at the department. The corresponding nationwide figure was 6.3% of all orthopedic operations, the number of implant removals in the whole country being 90 operations per 100,000 person-years. CONCLUSIONS Without a strict departmental removal policy, a remarkable portion of the resources allocated for elective orthopedic operations was spent on routine hardware removal procedures. A more rational and selective attitude toward implant removals is desirable. Further research on the disadvantages of retained hardware and the complications of implant removals is required.

Absorbable pins of self-reinforced poly-L-lactic acid for fixation of fractures and osteotomies

We reviewed 27 patients with small-fragment fractures or osteotomies treated by internal fixation with absorbable self-reinforced poly-L-lactide pins. The follow-up time ranged from eight to 37 months. The two most common indications were chevron osteotomy of the first metatarsal bone for hallux valgus and displaced fracture of the radial head. No redisplacements occurred, and there were no signs of inflammatory foreign-body reaction. Biopsy in two patients 20 and 37 months after implantation showed that no polymeric material remained.

Treatment with and without Initial Stabilizing Surgery for Primary Traumatic Patellar Dislocation A Prospective Randomized Study

BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.

The treatment of nonunions following intramedullary nailing of femoral shaft fractures.

Objective To assess the effectiveness of different surgical options in the treatment of nonunion of a femoral shaft fracture after initial intramedullary nailing. Design Retrospective. Setting University hospital. Patients and Methods During a seven-year period a total of 278 skeletally mature patients with 280 fresh femoral shaft fractures were treated by intramedullary nailing. Of these patients, a subgroup of consecutive patients with nonunion of the fracture were subjected to a detailed analysis and were followed until the fracture was united (mean thirty-three months). Injury mechanism, fracture pattern using various established classifications, any possible concomitant injuries, complications, and subsequent surgical interventions were recorded. Results Of the total of 280 fractures, nonunion was observed in thirty-four patients with thirty-five fractures (12.5 percent). To achieve solid union, one reoperation was sufficient in twenty-five fractures, six fractures had to be operated on twice, and four needed three operations. There were five patients with autogenous bone grafting alone, and all five required a further reoperation for the nonunion. After a dynamization procedure, four of seventeen patients required a further reoperation. After eight exchange nailing procedures, further surgery for nonunion was necessary in only one case. Solid union was achieved within six months after the final successful reoperation. A marked shortening of the femur developed as a local complication in six cases, four of which had undergone dynamization as final treatment before solid union. Conclusions Exchange nailing without extracortical bone grafting seems to be the most effective method to treat a disturbed union of a femoral shaft fracture after intramedullary nailing. Autogenous extracortical bone grafting alone proved to be insufficient. Dynamization predisposed to shortening of the bone.

Femoral Avulsion of the Medial Patellofemoral Ligament after Primary Traumatic Patellar Dislocation Predicts Subsequent Instability in Men: A Mean 7-Year Nonoperative Follow-Up Study

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.