Martti Hämäläinen

Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles rupture repair: a prospective, randomized, clinical study.

BACKGROUND The aim of our prospective, randomized, clinical study was to compare two postoperative regimens after Achilles rupture repair and determine whether early functional treatment will give a better result than early immobilization in tension of the musculotendinous unit. METHODS Fifty patients with acute Achilles tendon rupture were randomized postoperatively to receive either early movement of the ankle between neutral and plantar flexion in a brace for 6 weeks or Achilles tendon immobilization in tension using a below-knee cast with the ankle in a neutral position for 6 weeks. Full weight bearing was allowed after 3 weeks in both groups. The patients were assessed clinically at 1, 3, 6, 12, and 24 weeks, and the last control visit took place at a mean of 60 (SD 6.4) weeks postoperatively. RESULTS The isokinetic calf muscle strength scores were excellent in 56%, good in 32%, fair in 8%, and poor in 4% of the patients in the early motion group at the last control checkup; whereas the scores in the cast group were excellent in 29%, good in 50%, and fair in 21% of the patients. The ankle performance scores were excellent or good in 88%, fair in 4%, and poor in 8% of the patients in the early motion group, whereas the scores in the cast group were excellent or good in 92% and fair in 8% of the patients. At 3 months and at the last control checkup, no significant differences were seen between the two groups with regard to pain, stiffness, subjective calf muscle weakness, footwear restrictions, range of ankle motion, isokinetic calf muscle strength, or overall outcome. The complications included one rerupture in the early motion group and one deep infection and two reruptures in the cast group. Deep infection and the rerupture in the cast group occurred in the same patient. The outcome of the complications was good in two cases and poor in one. CONCLUSION The isokinetic calf muscle strength results were somewhat better in the early motion group, whereas the other outcome results obtained in the two groups of patients were very similar. We recommend early functional postoperative treatment after Achilles rupture repair for athletes and well-motivated patients and for less-motivated patients and nonathletes.

Intramedullary nailing of humeral shaft fractures. A retrospective study of 126 cases.

Antegrade intramedullary nailing with four different implants was used in 126 humeral shaft fractures. There were 74 acute fractures, 17 pathologic fractures, 16 fractures malaligned in a hanging cast or brace, 15 fractures with delayed union and 4 fractures that were nailed after failed open reduction and internal fixation. The nonunion rate was 21/95 after primary operation, and after reoperations 14/95. Distraction of the fracture was a significant cause of nonunion, but not type of fracture, localization, implant, and delay between injury and surgery. Shoulder joint function was significantly impaired in 25/67 patients. The patients regarded the result as good or satisfactory in 41/67 of the cases who were followed mean 3 (0.5-10) years. We conclude that antegrade intramedullary nailing of humeral shaft fractures leads to a substantial risk of non-union and impairment of shoulder function. It can be recommended as primary treatment only when nonoperative treatment is likely to fail.

The Souter-Strathclyde elbow arthroplasty: A CLINICAL AND RADIOLOGICAL STUDY OF 525 CONSECUTIVE CASES

We present the results of 525 primary Souter elbow arthroplasties undertaken in 406 patients between 1982 and 1997. There were 372 women and 34 men with a mean age of 57 years; 119 patients had a bilateral procedure. The elbows were affected by chronic inflammatory disease, usually rheumatoid arthritis, which had been present for a mean of 24.7 years (2 to 70). In about 30% the joints were grossly destroyed with significant loss of bone. In 179 elbows the ulnar components were metal-backed and retentive; in the remaining 346, with better bone stock, non-retentive, all-polyethylene prostheses were used. Because of complications, 108 further operations were required in 82 patients. During the early years the incidence of complications was higher. Dislocation was the indication for 30 further procedures in 26 patients. Thirty patients underwent 33 revision procedures for aseptic loosening, 12 had 29 operations because of deep infection, two for superficial infection, and 14 further operations were done for other reasons. The cumulative rate of success, without aseptic loosening, five and ten years after surgery, was 96% and 85%, respectively.

Registration of arthroplasties in Finland

Data on hip and knee arthroplasties have been compiled on a nationwide basis in Finland since 1980. Forty-five major departments contribute to the study providing data on the type of operation, the implant used, the diagnosis, and the 1-year clinical results. In the case of revision, new data are sent to the register, enabling survivorship analysis. Between 1980 and 1988, 25,966 operations were reported. Fifty-six percent had been made for primary osteoarthrosis, 22 percent for rheumatoid arthritis, 6.3 percent for secondary arthrosis, and 0.5 percent for CDH. In 1988, the total number of arthroplasties was 4,628: about two thirds hip and one third knee replacements. The annual incidence of primary total hip arthroplasties in 1988 was 58 per 100,000 inhabitants and that for the knees 25 per 100,000 inhabitants. More than 40 percent of the patients were under 65 years of age. In the whole series, primary thromboembolic complications occurred in 1.4 percent, luxations in 1.4 percent, infection in 0.9 percent, and evacuated hematoma in 0.6 percent. The annual frequency of re-arthroplasty increased between 1980 and 1988 from 9.8 to 13.6 percent, indicating an increasing orthopedic work load in the future.

Survival of the AGC total knee arthroplasty is similar for arthrosis and rheumatoid arthritis. Finnish Arthroplasty Register report on 8,467 operations carried out between 1985 and 1999.

We report the survival of AGC knee endoprosthesis from the Finnish Arthroplasty Register for 2 indications, osteoarthrosis (OA, 6 306 knees) and rheumatoid arthritis (RA, 2 161 knees) during 1985- 1999. Survivorship analysis was performed with revision as an endpoint. We found similar survival rates. In the OA group, survival after 5 years was 97% and it was 94% after 10 years. In the RA group the corresponding figures were 97% and 96%, respectively. There was no significant difference in survival whether or not cement was used for fixation. The revision rates were higher in men and in younger patients.

Corrective osteotomy for malunion of the distal radius.

Abstract Forty-five patients were reviewed on average 5.7 years after corrective osteotomy for symptomatic distal radius malunion. Restoration of anatomy and function was assessed compared with the contralateral wrist. It was found that osteotomy of the distal radius alone did not completely restore normal anatomy and relieve symptoms, and in several cases a second operation was needed. Osteoarthritic changes in the radiocarpal and radioulnar joints were common, and they correlated with restriction in range of motion, but not with pain. Range of motion and grip power were reduced compared to the unaffected hand, but only loss of supination and ulnar deviation correlated with an unsatisfactory subjective result. The result was good or satisfactory in 33 of the 45 patients. We conclude that reconstructive procedures in patients with distal radius malunion may not completely restore normal function, and every effort should therefore be made to prevent malunion in the treatment of distal radius fractures.

Charnley low-friction arthroplasty in rheumatoid patients: A survival study up to 20 years☆

The survivorship of 1,553 consecutive Charnley low-friction arthroplasties (LFA) in 1,086 patients with rheumatoid arthritis (RA) were analyzed. There were 846 women (1,236 hips) and 240 men (317 hips), with a mean age of 53.1 years (range, 24-77 years; standard deviation, 10.7). A uniform postoperative regimen with protected weight bearing for 2 months (6 months in patients with bone grafting on the acetabular side) was used throughout the whole study. The overall survival with revision as the endpoint was 90.5% (95% confidence interval [CI], 88.7-92.2) at 10 years and 83% (95% CI, 80.3-85.7) at 15 years. The survival of the femoral component was 93.2% (95% CI, 91.8-96.7) and 89.9% (95% CI, 88.0-93.0) at 10 and 15 years, and survival of the acetabulum was 93.6% (95% CI, 92.1-95.1) and 87.1% (95% CI, 84.6-89.5) at 10 and 15 years. The indication for revision was late deep infection in 19 patients (1.2%) and in others aseptic loosening of prosthetic components. Young age, male sex, and secondary reactive amyloidosis impaired significantly the survival of LFA in the RA patients. In all, cemented LFA provided good results, and it can be justified for the treatment of hip destruction in RA.

Multidisciplinary rehabilitation after primary total knee arthroplasty: a randomized, controlled study of its effects on functional capacity and quality of life

Objective: To examine whether a multidisciplinary rehabilitation programme can improve functional recovery and quality of life and reduce the use of rehabilitation services compared with conventional care one year after total knee arthroplasty. Design: Prospective, randomized, non-blinded, controlled trial. Setting: An outpatient centre-based setting. Subjects: Eighty-six patients who were scheduled for primary total knee arthroplasty due to osteoarthritis of the knee. Interventions: A ten-day multidisciplinary rehabilitation programme, which was focused on enhancing functional capacity, was organized 2—4 months after surgery. In both groups, a standard amount of physiotherapy was included in conventional care. Main measures: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the 15D, 15-m walk test, stair test, isometric strength measurement of the knee. Use of rehabilitation services was asked about with a questionnaire. Outcomes were assessed preoperatively and at 2-, 6- and 12-month follow-ups. Results: In both groups, functional capacity and quality of life improved significantly. The mean absolute change in the WOMAC function score was —32.4 mm (SD 26.4) in the rehabilitation group and —32.8 mm (SD 20.1) in the control group (P-time*group = 0.40). No difference was found between groups in any outcome measure or in the use of rehabilitation services during the study period. Conclusions: This study indicates that for knee osteoarthritis patients treated with primary total knee arthroplasty, a 10-day multidisciplinary outpatient rehabilitation programme 2—4 months after surgery does not yield faster attainment of functional recovery or improvement in quality of life than can be achieved with conventional care.

The Souter-Strathclyde elbow arthroplasty

We present the results of 525 primary Souter elbow arthroplasties undertaken in 406 patients between 1982 and 1997. There were 372 women and 34 men with a mean age of 57 years; 119 patients had a bilateral procedure. The elbows were affected by chronic inflammatory disease, usually rheumatoid arthritis, which had been present for a mean of 24.7 years (2 to 70). In about 30% the joints were grossly destroyed with significant loss of bone. In 179 elbows the ulnar components were metal-backed and retentive; in the remaining 346, with better bone stock, non-retentive, all-polyethylene prostheses were used. Because of complications, 108 further operations were required in 82 patients. During the early years the incidence of complications was higher. Dislocation was the indication for 30 further procedures in 26 patients. Thirty patients underwent 33 revision procedures for aseptic loosening, 12 had 29 operations because of deep infection, two for superficial infection, and 14 further operations were done for other reasons. The cumulative rate of success, without aseptic loosening, five and ten years after surgery, was 96% and 85%, respectively.

Recovery of shoulder joint function after humeral shaft fracture: a comparative study between antegrade intramedullary nailing and plate fixation.

IntroductionAntegrade intramedullary (IM) nailing of humeral shaft fractures is reported to cause shoulder joint impairment. This retrospective study compared shoulder joint symptoms, range of motion (ROM), and isometric strength after antegrade IM nailing and dynamic compression (DC) plating of humeral shaft fractures.Materials and methodsWe compared 29 patients with DC plating and 44 with antegrade IM nailing of their humeral shaft fractures. Shoulder pain, L’Insalata and Constant scores, shoulder joint ROM and isometric shoulder strengths were measured after mean follow-up of 6.2 (1–15) years (DC plating) and 5.5 (2–10) years (IM nailing).ResultsPatients had nonsignificantly more shoulder pain after IM nailing than after DC plating. Shoulder scores and isometric strength measurements showed no difference between the groups. Flexion was significantly better after DC plating, but none of the other ROM parameters differed between the groups. The shoulder scores and all ROM and strength parameters of the injured side were significantly lower than on the uninjured side in both groups.ConclusionsShoulder joint ROM and strength does not recover to normal after humeral shaft fracture. Antegrade IM nailing if performed properly is not responsible for shoulder joint impairment.