Heidi Haapasalo

Good maintenance of exercise-induced bone gain with decreased training of female tennis and squash players: a prospective 5-year follow-up study of young and old starters and controls.

This prospective 5‐year follow‐up study of 64 adult female racquet sports players and 27 controls assessed the changes in the playing‐to‐nonplaying arm bone mineral content (BMC) differences to answer three questions: (1) Are training‐induced bone gains lost with decreased training? (2) Is the bone response to decreased training different if the playing career has been started before or at puberty rather than after it? (3) Are the possible bone changes related to the changes in training? The players were divided into two groups according to the starting age of their tennis or squash playing. The mean starting age was 10.5 years (SD, 2.2) among the players who had started training before or at menarche (young starters; n = 36) while 26.4 years (SD, 8.0) among those players who had begun training a minimum of 1 year after menarche (old starters; n = 28). At baseline of the 5‐year follow‐up, the mean age of the young starters was 21.6 years (SD, 7.6) and that of old starters was 39.4 years (SD, 10.5). During the follow‐up, the young starters had reduced the average training frequency from 4.7 times a week (2.7) to 1.4 times a week (1.3) and the old starters from 4.0 times a week (1.4) to 2.0 times a week (1.4), respectively. The 5‐year follow‐up revealed that despite reduced training the exercise‐induced bone gain was well maintained in both groups of players regardless of their clearly different starting age of activity and different amount of exercise‐induced bone gain. The gain was still 1.3–2.2 times greater in favor of the young starters (at the follow‐up, the dominant‐to‐nondominant arm BMC difference was 22% [8.4] in the humeral shaft of the young starters versus 10% [3.8] in the old starters, and 3.5% [2.4] in controls). In the players, changes in training were only weakly related to changes in the side‐to‐side BMC difference (rs = 0.05–0.34, all NS), and this was true even among the players who had stopped training completely a minimum 1 year before the follow‐up. In conclusion, if controlled interventions will confirm our findings that an exercise‐induced bone gain can be well maintained with decreased activity and that the maintenance of the bone gain is independent of the starting age of activity, exercise can be recommended for preventing osteoporosis and related fractures.

A controlled trial of the health benefits of regular walking on a golf course

PURPOSE To study the effects of regular walking during a golf game on various health and fitness indicators in middle-aged men. METHODS Study subjects were 55 healthy male golfers aged 48 to 64 years who had been sedentary during the 7 months before the study, and 55 age-matched, similarly sedentary controls. During the 20-week study, those in the intervention group were encouraged to play golf two to three times a week; the controls were not. Measurements of body composition, cardiorespiratory performance, motor and musculoskeletal fitness, blood pressure, and serum lipid, glucose, and insulin levels were obtained at baseline and after the 20-week study. RESULTS Walking during a golf game was a practical and safe form of physical activity with high adherence. It significantly increased aerobic performance and trunk muscle endurance, with a net difference (pretraining to posttraining change between the golfers and controls) of 36 seconds (95% confidence interval [CI]: 19 to 53 seconds, P < 0.001) for treadmill walking time and 13 seconds (95% CI: 2 to 24 seconds, P = 0.02) for static back extension. In addition, regular walking favorably affected body composition, including reductions in weight of 1.4 kg (95% CI: 0.6 to 2.1 kg, P < 0.001), in waist circumference of 2.2 cm (95% CI: 1.0 to 3.3 cm, P < 0.001), and in abdominal skin fold thickness of 2.2 cm (95% CI: 0.9 to 3.4 cm, P = 0.001). Golfers also had significantly greater increases in serum high-density lipoprotein (HDL) cholesterol levels and in the ratio of HDL cholesterol to total cholesterol. CONCLUSIONS Regular walking had many positive effects on the health and fitness of sedentary middle-aged men. Walking during a golf game is characterized by high adherence and low risk of injury and is therefore a good form of health-enhancing physical activity.

Declining incidence of surgery for Achilles tendon rupture follows publication of major RCTs: evidence-influenced change evident using the Finnish registry study

Objectives Acute Achilles tendon ruptures are common among highly active people. Recently published studies have provided increasing evidence to support non-surgical treatment. This study aimed to assess the incidence trends of surgically treated, acute Achilles tendon ruptures. Our hypothesis, based on the recent literature showing no difference in functional results between surgical and non-surgical treatment, was that the incidence of surgery would be declining. Methods We conducted a nationwide hospital register-based study. All patients 18 years of age or older with a diagnosis of acute Achilles tendon injury, and treated with Achilles tendon repair from 1987 to 2011 in Finland were included in the study. Results During the 25-year study period in Finland, a total of 15 252 patients received surgical treatment for an acute Achilles tendon rupture. The incidence of surgical treatment of acute Achilles tendon rupture in men was 11.1/100 000 person-years in 1987 and 20.5/100 000 person-years in 2011. The corresponding figures in women were 2.5/100 000 person-years in 1987 and 4.2/100 000 person-years in 2011. The highest rates occurred in 2008 in men and 2007 in women, and since then the decrease has been 42% in men and 55% in women. Conclusions During the past few years, the rate of surgically treated acute Achilles tendon ruptures has declined remarkably. The findings of the present study indicate that orthopaedic surgeons have chosen more often non-surgical treatment option for acute Achilles ruptures. This can be considered as an example, how high-quality scientific evidence can lead to a rapid change in clinical practice.

Hypertrophy of the flexor hallucis longus muscle after tendon transfer in patients with chronic Achilles tendon rupture

BACKGROUND Flexor hallucis longus tendon (FHLT) transfer has become a popular method for reconstructing a chronic Achilles tendon rupture (ATR). The purpose of this study was to evaluate the clinical outcomes and possible hypertrophy of the FHL muscle after FHLT transfer in patients with chronic ATR. METHODS Seven patients with chronic ATR underwent an FHLT transfer to heel through single incision. The patients were clinically evaluated 27 (16-39) months after the surgery. The patient satisfaction was assessed with Achilles Tendon Total Rupture Scale (ATRS). Isokinetic strength was measured from both legs. The FHL muscle hypertrophy was evaluated from MRI of both legs. All subjects also performed a gait analysis with an instrumented walkway system (GAITRite(®)). RESULTS The plantar flexion strength was 16.1% (-45, 7-2, 4%) weaker in the operated leg. ATRS scores averaged 70.3. Marked hypertrophy, +52% (9-104%) of the FHL muscle was seen in the operated leg compared to the non-operated leg. The gait analysis did not show any marked pathology in any of the patients. CONCLUSIONS A mean hypertrophy of 52% of the FHL muscle was found after FHLT transfer for the chronic ATR. This indicates strong adaptation capacity of this muscle after FLHT transfer in situation where the function of the gastro-soleus complex was severely impaired preoperatively. The reconstruction of chronic ATR with FHLT transfer provided a good functional outcome and excellent patient satisfaction.

Incidence and Characteristics of Midfoot Injuries

Background: The epidemiology of midfoot injuries is poorly known. It has been estimated that the incidence of Lisfranc injuries (intra-articular injury in the tarsometatarsal joint) is 1/55 000 person-years and the incidence of Chopart injuries (intra-articular injury in the talonavicular and calcaneocuboidal joint) 4/100 000 person-years. The purpose of our study was to assess the computed tomography (CT) imaging–based incidence (per 100 000 person-years) and trauma mechanisms of midfoot injuries. Methods: All CT studies performed due to acute injury of the foot and ankle region between January 1, 2012, and December 31, 2016, at Tampere University Hospital were reviewed. Patients presenting with an injury in the midfoot region in the CT scan were included in this study, and their records were retrospectively evaluated to assess patient characteristics. Results: During the 5-year study period, 953 foot and ankle CT scans were obtained because of an acute injury of the foot and ankle. Altogether, 464 foot injuries were found. Of these, 307 affected the midfoot area: 233 (75.9%) the Lisfranc joint area, 56 (18.2%) the Chopart joint area, and 18 (5.9%) were combined injuries or miscellaneous injuries in the midfoot. The incidence of all midfoot injuries was 12.1/100 000 person-years. The incidence of Lisfranc injuries was 9.2/100 000 person-years. The incidence of Chopart injuries was 2.2/100 000 person-years. Conclusions: The incidence of Lisfranc injuries was higher and the incidence of Chopart injuries lower than previously estimated. More than two-thirds of the midfoot injuries in this study were nondisplaced (<2 mm displacement in fracture or joint) and were caused by low-energy trauma. Level of Evidence: Level III, epidemiologic study.

Overuse injuries are prevalent in children’s competitive football: a prospective study using the OSTRC Overuse Injury Questionnaire

Objectives To investigate the prevalence and burden of overuse injuries in children’s football as well as player characteristics and their association with overuse injury risk. Methods This investigation is based on the control arm (10 clubs) of a randomised controlled trial investigating prevention of injuries in youth football. We conducted a prospective 20-week follow-up study on overuse injuries among Finnish football players (n=733, aged 9–14 years). Each week, we sent a text message to players’ parents to ask if the player had sustained any injury during the past week. Players with overuse problem were interviewed over the phone using an overuse injury questionnaire. The main outcome measures were prevalence of all overuse injuries and substantial overuse injuries (those leading to moderate or severe reductions in participation or performance) and injury severity. Results The average response rate was 95%. In total, 343 players (46.8%) reported an overuse problem while in the study. The average weekly prevalence of all overuse problems and substantial overuse problems was 12.8% and 6.0%, respectively. Injuries affecting the knee had the highest weekly prevalence (5.7% and 2.4% for all and substantial knee problems, respectively). Girls had a higher likelihood of knee problems (OR 2.70; 95% CI 1.69 to 4.17), whereas boys had a higher likelihood of heel problems (OR 2.82; 95% CI 1.07 to 7.44). The likelihood of reporting an overuse problem increased with age (OR 1.21; 95% CI 1.00 to 1.47). Conclusion Overuse injuries are prevalent in children’s competitive football. Knee overuse injuries represent the greatest burden on participation and performance. Trial registration number ISRCTN14046021.

Nonoperative, open reduction and internal fixation or primary arthrodesis in the treatment of Lisfranc injuries: a prospective, randomized, multicenter trial – study protocol

BackgroundLisfranc injuries are known to be rare and often overlooked injuries that can cause long-term disability and pain when missed or treated incorrectly. The wide variety of Lisfranc injuries ranges from subtle ligament distensions to open fracture dislocations. The treatment of Lisfranc joint injuries is still controversial and very little is known about what types of injury can be treated nonoperatively. The current literature provides only two randomized studies on dislocated Lisfranc injuries. These studies have shown that primary arthrodesis (PA) leads to a similar or better outcome and results in fewer secondary operations when compared with open reduction and internal fixation (ORIF) in ligamentous injuries. There have been no previous randomized studies of the nonoperative versus operative treatment of Lisfranc injuries. Therefore, the purpose of this study is to compare the operative and nonoperative treatment of non-dislocated Lisfranc injuries and to compare the ORIF and PA treatment of dislocated Lisfranc injuries.MethodsThis study is a prospective, randomized, national multi-center trial. The trial comprises two strata: Stratum I compares cast-immobilization versus open reduction and internal fixation (ORIF) treatment of non-dislocated Lisfranc joint injuries. Stratum II compares PA versus ORIF in the treatment of dislocated injuries of the Lisfranc joint. The main hypothesis of stratum I is that the nonoperative treatment of non-dislocated Lisfranc injuries achieves a similar outcome compared with operative treatment (ORIF). The hypothesis of stratum II is that PA of dislocated Lisfranc injuries yields a similar functional outcome compared with ORIF, but that PA results in fewer secondary operations than ORIF. The main outcome measure is the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot score and the secondary outcome measures are Visual-Analogue-Scale Foot and Ankle (VAS-FA), Visual-Analogue-Scale (VAS), rate of secondary operations and other treatment-related complications. The results will be analyzed after the 2-year follow-up period.DiscussionThis publication presents a prospective, randomized, national multi-center trial study protocol. It provides details of patient flow, randomization, aftercare and methods of analysis of the material and ways to present and publish the results.Trial registrationClinicalTrials.gov identifier: NCT02953067 24.10.2016.

Treatment of acute Achilles tendon rupture with a standardised protocol

IntroductionA treatment protocol favouring non-operative treatment and based on early weight-bearing and early range-of-motion exercises was implemented in standard clinical care of a level I trauma clinic.Materials and methodsAll patients treated due to acute Achilles tendon rupture between 2008 and 2014 were included in the study (n = 411). The patient records were retrospectively evaluated.ResultsThe mean age of patients was 47 (range 17–88) years. In total, 213 (52%) acute Achilles tendon ruptures were treated operatively and 198 (48%) non-operatively. The annual proportion of operatively treated patients declined from 70 to 21% during the study period. The traumatic re-rupture rate was similar between the operative (4%) and the non-operative (6%) treatment groups (p = 0.385), even though the patients in the non-operative group were significantly older and had more co-morbidities than the operatively treated patients. Of the operatively treated patients, 10% (n = 21) had wound healing problems. In 6/198 patients, the non-operative treatment had to be converted to surgical treatment in the early phase. Unsatisfactory functional outcome after the treatment was reported in 7/213 patients in the operative and 10/198 in the non-operative group (p = 0.234).ConclusionsOur study showed that it is possible to implement a standardised treatment protocol to guide the decision-making and treatment and of an acute Achilles tendon rupture as a part of the daily care in a large standard trauma hospital. The clinical outcome and the rate of complications were fully comparable to the good clinical results achieved in RCT-study settings despite the heterogeneity of the treated patients and non-specialisation of the medical staff, showing that the protocol could find the most reasonable treatment for each patient and reduced dramatically the rate of operative treatment.Level of evidenceLevel III, comparative series.

Epidemiology of calcaneal fractures in Finland

BACKGROUND The purpose of this study was to assess the nationwide incidence (per 100,000 person-years) of operative treatment and hospitalization due to calcaneal fractures (CF) in Finland. METHODS The study was based on the Finnish National Hospital Discharge Register. All patients aged 18-years or older admitted to Finnish hospitals for primary treatment of CF in 1987-2012 were included. RESULTS During the 26-year study period 5977 patients were hospitalized with main or secondary diagnosis of a CF. The incidence of hospitalization due to CF remained relatively stable: (12.5)/100,000 in men and 3.9/100,000 in women. The men were younger (median 43 years) than the women (median 61 years). CONCLUSIONS The incidence of the hospitalization due to CF in Finland has remained at steady level during the past 26 years. The incidence of CF is three times higher in men. In 2012 22% of the fractures were operatively treated.

Re-organizing inpatient care saves legs in patients with diabetic foot infections

AIMS In this study, we evaluated the effects of the re-organization of inpatient care for patients with a diabetic foot infection, and the implementation of a specialized multi-disciplinary wound department at an academic tertiary hospital. METHODS This was a retrospective cohort study, comprising 272 patients treated for diabetic foot infections in 2006-2007 (Group 1, n=124) and 2013-2014 (Group 2, n=148). In 2012, inpatient care of all chronic wounds was centralized at a single wound department with a multi-disciplinary team. We assessed group outcome before and after the re-organization. RESULTS During the 7-year study period, the incidence of hospitalized patients with a diabetic foot infection increased 19%. After initiating the re-organization, the below-the-knee amputation rate was significantly reduced (25.8% vs. 9.5%, p<0.001). The median time from admission to surgical intervention decreased from 5days to 2days, p<0.001. The length of hospitalization also tended to decrease after the reorganization. CONCLUSIONS The findings of this study demonstrate the benefits of treating diabetic foot infections at a specialized wound department with a multi-disciplinary team. The benefits were achieved by simply distributing the workload and organizing schedules, without new investments or additional personnel. The findings of this study indicate that patients with diabetic foot infections present a challenge that is beyond the expertise of a single field of medicine. A working collaboration between disciplines and a specialized wound department are central in achieving better results.