Juha Paloneva

Changes in rates of arthroscopy due to degenerative knee disease and traumatic meniscal tears in Finland and Sweden

Background and purpose — Knee arthroscopy is commonly performed to treat degenerative knee disease symptoms and traumatic meniscal tears. We evaluated whether the recent high-quality randomized control trials not favoring arthroscopic surgery for degenerative knee disease affected the procedure incidence and trends in Finland and Sweden. Patients and methods — We conducted a bi-national registry-based study including all adult (aged ≥18 years) inpatient and outpatient arthroscopic surgeries performed for degenerative knee disease (osteoarthritis (OA) and degenerative meniscal tears) and traumatic meniscal tears in Finland between 1997 and 2012, and in Sweden between 2001 and 2012. Results — In Finland, the annual number of operations was 16,389 in 1997, reached 20,432 in 2007, and declined to 15,018 in 2012. In Sweden, the number of operations was 9,944 in 2001, reached 11,711 in 2008, and declined to 8,114 in 2012. The knee arthroscopy incidence for OA was 124 per 105 person-years in 2012 in Finland and it was 51 in Sweden. The incidence of knee arthroscopies for meniscal tears coded as traumatic steadily increased in Finland from 64 per 105 person-years in 1997 to 97 per 105 person-years in 2012, but not in Sweden. Interpretation — The incidence of arthroscopies for degenerative knee disease declined after 2008 in both countries. Remarkably, the incidence of arthroscopy for degenerative knee disease and traumatic meniscal tears is 2 to 4 times higher in Finland than in Sweden. Efficient implementation of new high-quality evidence in clinical practice could reduce the number of ineffective surgeries.

Incidence of fractures requiring inpatient care

Background — The overall incidence of fractures has been addressed in several studies, but there are few data on different types of fractures that require inpatient care, even though they account for considerable healthcare costs. We determined the incidence of limb and spine fractures that required hospitalization in people aged ≥ 16 years. Patients and methods — We collected data on the diagnosis (ICD10 code), procedure code (NOMESCO), and 9 additional characteristics of patients admitted to the trauma ward of Central Finland Hospital between 2002 and 2008. Incidence rates were calculated for all fractures using data on the population at risk. Results and interpretation — During the study period, 3,277 women and 2,708 men sustained 3,750 and 3,030 fractures, respectively. The incidence of all fractures was 4.9 per 103 person years (95% CI: 4.8–5.0). The corresponding numbers for women and men were 5.3 (5.1–5.4) and 4.5 (4.3–4.6). Fractures of the hip, ankle, wrist, spine, and proximal humerus comprised two-thirds of all fractures requiring hospitalization. The proportion of ankle fractures (17%) and wrist fractures (9%) was equal to that of hip fractures (27%). Four-fifths of the hospitalized fracture patients were operated. In individuals aged < 60 years, fractures requiring hospitalization were twice as common in men as in women. In individuals ≥ 60 years of age, the opposite was true.

Declining incidence of acromioplasty in Finland

Background and purpose — An increased incidence rate of acromioplasty has been reported; we analyzed data from the Finnish National Hospital Discharge Register. Patients and methods — During the 14-year study period (1998–2011), 68,877 acromioplasties without rotator cuff repair were performed on subjects aged 18 years or older. Results — The incidence of acromioplasty increased by 117% from 75 to 163 per 105 person years between 1998 and 2007. The highest incidence was observed in 2007, after which the incidence rate decreased by 20% to 131 per 105 person years in 2011. The incidence declined even more at non-profit public hospitals from 2007 to 2011. In contrast, it continued to rise at profit-based private orthopedic clinics. Interpretation — We propose that this change in clinical practice is due to accumulating high-quality scientific evidence that shows no difference in outcome between acromioplasty and non-surgical interventions for rotator cuff disease with subacromial impingement syndrome. However, the exact cause of the declining incidence cannot be defined based solely on a registry study. Interestingly, this change was not observed at private clinics, where the number of operations increased steadily from 2007 to 2011.

Hospital volume affects outcome after total knee arthroplasty A nationwide registry analysis of 80 hospitals and 59,696 replacements

Background and purpose — The influence of hospital volume on the outcome of total knee joint replacement surgery is controversial. We evaluated nationwide data on the effect of hospital volume on length of stay, re-admission, revision, manipulation under anesthesia (MUA), and discharge disposition for total knee replacement (TKR) in Finland. Patients and methods — 59,696 TKRs for primary osteoarthritis performed between 1998 and 2010 were identified from the Finnish Hospital Discharge Register and the Finnish Arthroplasty Register. Hospitals were classified into 4 groups according to the number of primary and revision knee arthroplasties performed on an annual basis throughout the study period: 1–99 (group 1), 100–249 (group 2), 250–449 (group 3), and ≥ 450 (group 4). The association between hospital procedure volume and length of stay (LOS), length of uninterrupted institutional care (LUIC), re-admissions, revisions, MUA, and discharge disposition were analyzed. Results — The greater the volume of the hospital, the shorter was the average LOS and LUIC. Smaller hospital volume was not unambiguously associated with increased revision, re-admission, or MUA rates. The smaller the annual hospital volume, the more often patients were discharged home. Interpretation — LOS and LUIC ought to be shortened in lower-volume hospitals. There is potential for a reduction in length of stay in extended institutional care facilities.

Hospital volume affects outcome after total knee arthroplasty

Background and purpose — The influence of hospital volume on the outcome of total knee joint replacement surgery is controversial. We evaluated nationwide data on the effect of hospital volume on length of stay, re-admission, revision, manipulation under anesthesia (MUA), and discharge disposition for total knee replacement (TKR) in Finland. Patients and methods — 59,696 TKRs for primary osteoarthritis performed between 1998 and 2010 were identified from the Finnish Hospital Discharge Register and the Finnish Arthroplasty Register. Hospitals were classified into 4 groups according to the number of primary and revision knee arthroplasties performed on an annual basis throughout the study period: 1–99 (group 1), 100–249 (group 2), 250–449 (group 3), and ≥ 450 (group 4). The association between hospital procedure volume and length of stay (LOS), length of uninterrupted institutional care (LUIC), re-admissions, revisions, MUA, and discharge disposition were analyzed. Results — The greater the volume of the hospital, the shorter was the average LOS and LUIC. Smaller hospital volume was not unambiguously associated with increased revision, re-admission, or MUA rates. The smaller the annual hospital volume, the more often patients were discharged home. Interpretation — LOS and LUIC ought to be shortened in lower-volume hospitals. There is potential for a reduction in length of stay in extended institutional care facilities.

Increased mortality after upper extremity fracture requiring inpatient care

Background and purpose — Increased mortality after hip fracture is well documented. The mortality after hospitalization for upper extremity fracture is unknown, even though these are common injuries. Here we determined mortality after hospitalization for upper extremity fracture in patients aged ≥16 years. Patients and methods — We collected data about the diagnosis code (ICD10), procedure code (NOMESCO), and 7 additional characteristics of 5,985 patients admitted to the trauma ward of Central Finland Hospital between 2002 and 2008. During the study, 929 women and 753 men sustained an upper extremity fracture. The patients were followed up until the end of 2012. Mortality rates were calculated using data on the population at risk. Results — By the end of follow-up (mean duration 6 years), 179 women (19%) and 105 men (14%) had died. The standardized mortality ratio (SMR) for all patients was 1.5 (95% CI: 1.4–1.7). The SMR was higher for men (2.1, CI: 1.7–2.5) than for women (1.3, CI: 1.1–1.5) (p < 0.001). The SMR decreased with advancing age, and the mortality rate was highest for men with humerus fractures. Interpretation — In men, the risk of death related to proximal humerus fracture was even higher than that reported previously for hip fracture. Compared to the general population, the SMR was double for humerus fracture patients, whereas wrist fracture had no effect on mortality.

Physical Activity Is Related with Cartilage Quality in Women with Knee Osteoarthritis

Purpose To study the relationship between 12-month leisure-time physical activity (LTPA) level and changes in estimated biochemical composition of tibiofemoral cartilage in postmenopausal women with mild knee osteoarthritis (OA). Methods Originally, 87 volunteer postmenopausal women, age 60 to 68 yr, with mild knee OA (Kellgren Lawrence I/II and knee pain) participated in a randomized controlled, 4-month aquatic training trial (RCT), after which 76 completed the 12-month postintervention follow-up period. Self-reported LTPA was collected along the 12-month period using a diary from which MET task hours per month were calculated. Participants were divided into MET task hour tertiles: 1, lowest (n = 25); 2 = middle (n = 25) and 3 = highest (n = 26). The biochemical composition of the cartilage was estimated using transverse relaxation time (T2) mapping sensitive to the properties of the collagen network and delayed gadolinium-enhanced magnetic resonance imaging of the cartilage (dGEMRIC index) sensitive to the cartilage glycosaminoglycan content. Secondary outcomes were cardiorespiratory fitness, isometric knee extension and flexion force, and the knee injury and OA outcome questionnaire. Results During the 12-month follow-up period, there was a significant linear relationship between higher LTPA level and increased dGEMRIC index changes in the posterior region of interest (ROI) of the lateral (P = 0.003 for linearity) and medial (P = 0.006) femoral cartilage. Furthermore, these changes were seen in the posterior lateral femoral cartilage superficial (P = 0.004) and deep (P = 0.007) ROI and in the posterior medial superficial ROI (P < 0.001). There was no linear relationship between LTPA level and other measured variables. Conclusions These results suggest that higher LTPA level is related to regional increases in estimated glycosaminoglycan content of tibiofemoral cartilage in postmenopausal women with mild knee OA as measured with dGEMRIC index during a 12-month period.

Reliability and validity of the Finnish version of the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section

BackgroundThe American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) is one of the most widely used shoulder outcome tools in clinical work and in scientific studies. However, it has not been validated in the Finnish language. The aims of this study were to cross-culturally adapt the ASES to the Finnish language and to study the psychometric properties of the self-report section of the ASES.MethodsA total of 105 patients with shoulder symptoms answered the questionnaires of the ASES, a single disability question, the Simple Shoulder Test (SST), and the Short-Form 36 Health Survey (SF-36). The reliability of the ASES questionnaire was studied using a test-retest procedure at 2-week intervals. Psychometric assessment was performed by testing the construct validity, internal consistency, the criterion validity, and the convergent validity of the ASES.ResultsThe reproducibility and internal consistency of the ASES were 0.83 (95% CI 0.70 to 0.90) and 0.88 (95% Cl 0.84 to 0.91). There were no significant differences between the diagnostic groups in the pain scores from the ASES, and the function score was significantly higher in the instability group compared to the other groups. The convergent validity of the ASES correlated with the SST, r = 0.73 (p < 0.001); the single disability question, r = -0.74 (p < 0.001); and the Physical Component Score of the SF-36, r = 0.57 (p < 0.001).ConclusionsThe Finnish version of the ASES proved to be a reliable and valid tool for assessing shoulder disabilities in patients with different shoulder diagnoses, including rotator cuff disease, instability, and osteoarthritis.

Increased mortality after lower extremity fractures in patients <65 years of age

Background and purpose — The association between mortality and lower extremity fractures (other than hip fractures in older individuals) is unclear. We therefore investigated mortality in adults of all ages after lower extremity fractures that required inpatient care. Patients and methods — Diagnosis code (ICD10), procedure code (NOMESCO), and 7 additional characteristics of patients admitted to the trauma ward at Central Finland Hospital were collected between 2002 and 2008 (n = 3,567). Patients were followed up until the end of 2012. Mortality rates were calculated for patients with all types of lower extremity fractures using data from the population at risk. Results — During the study, 2,081 women and 1,486 men sustained a lower extremity fracture. By the end of follow-up (mean duration 5 years), 42% of the women and 32% of the men had died. For all lower extremity fractures, the standardized mortality ratio (SMR) was 1.9 (95% CI: 1.8–2.0) for women and 2.6 (CI: 2.4–2.9) for men. In patients aged ≥65 years, mortality was increased and of similar magnitude after fractures of the hip, femoral diaphysis, and knee (distal femur, patella, and proximal tibia). In patients aged <65 years, mortality was increased after fractures at all sites. The SMR after fractures at different sites ranged between 2.1 (CI: 1.4–3.2) (ankle) and 6.7 (CI: 5.0–9.0) (hip) in patients aged <65 years and between 0.6 (CI: 0.30–1.1) (leg) and 2.2 (CI: 2.0–2.3) (hip) in patients aged ≥65 years. Interpretation — The post-fracture SMR of patients aged <65 years was at least double that of older patients. Furthermore, the higher mortality observed after proximal fractures of the lower extremity was greater in younger patients. The reasons behind these findings remain unclear.

Specific spinal pathologies in adult patients with an acute or subacute atraumatic low back pain in the emergency department

PurposeThe primary aim in the evaluation of patients presenting with acute or subacute low back pain (LBP) is to exclude a possible specific spinal pathology. Literature on the population-based incidences of these pathologies is scarce. The aim of our study was to investigate the population-based incidence of specific spinal pathologies as a cause of atraumatic acute or subacute LBP.MethodsFrom our institutional database, we identified all patients with a relevant LBP-related ICD-10 code during a visit to our emergency department (ED) in a level II/III teaching hospital between January 2012 and December 2014. Patients with a possible specific spinal pathology (cauda equina syndrome, spondylodiscitis, vertebral fracture, and cancer) were assessed in detail.ResultsA total of 900 visits were due to atraumatic low back pain. Of these 284 (31.6%) were due to nonspecific LBP, and 583 (64.8%) due to radicular pain suggesting nerve root compression. In 33 (3.7%) cases, the LBP was caused by a specific spinal pathology. The annual incidences per 100,000 were 0.60 for CES, 2.1 for spondylodiscitis, 0.76 for cancer and 1.2 for compression fracture.ConclusionsThe incidences of specific spinal pathologies were low. Given that LBP is a very common symptom, it is not surprising that the accuracy of red flag symptoms is poor. Each patient should be considered individually, and we advocate a low threshold for referral and advanced imaging in cases where a specific spinal pathology is suspected.