Pasi Ohtonen

Achilles Tendon Elongation After Rupture Repair A Randomized Comparison of 2 Postoperative Regimens

Background A few prospective controlled trials comparing early functional rehabilitation after Achilles tendon repair and non-operative immobilization have been reported. Hypotheses There is no difference in Achilles tendon elongation between early motion and immobilization after Achilles tendon repair. Tendon elongation does not correlate with the clinical outcome. Study Design Randomized clinical trial; Level of evidence, 2. 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 immobilization in tension using a below-knee cast with the ankle in a neutral position for 6 weeks. Full weightbearing was allowed after 3 weeks in both groups. Standardized radiographs to measure previously placed radiographic markers were taken on the first day postoperatively and at 1, 3, 6, 12, 24 weeks postoperatively, with the final radiograph a mean of 60 (SD, 6.4) weeks postoperatively. The outcome was assessed at the 3-month and final checkups by the clinical scoring method described by Leppilahti et al and included subjective factors and objective factors. Results Tendon elongation occurred in both groups but was somewhat less in the early motion group (median 2 mm in the early motion group vs median 5 mm in the cast group a mean of 60 weeks postoperatively, P = .054). The elongation curves first rose and then slowly fell in both groups. The patients who had less elongation achieved a better clinical outcome (ρ= -.42, P = .017). Tendon elongation did not correlate significantly with age, body mass index, or isokinetic peak torques. Conclusion Achilles tendon elongation was somewhat less in the early motion group and correlated with the clinical outcome scores. We recommend early functional postoperative treatment after Achilles rupture repair.

Rerupture and deep infection following treatment of total Achilles tendon rupture

Background: The incidence of total Achilles tendon rupture has increased, but we are not aware of any reports on the incidence of reruptures or deep infections following treatment. The outcome after successful treatment is good, but that after complications has not been well documented.Methods: A group of 409 patients with a complete Achilles tendon rupture was treated at a university hospital orthopaedic unit between 1979 and 2000. Twenty-three reruptures (prevalence, 5.6%) and nine deep infections (prevalence, 2.2%) occurred in twenty-nine patients. We retrospectively reviewed the records of these patients to determine the overall incidence of ruptures, reruptures, and deep infections and to record the known risk factors for these major complications. We analyzed the final clinical outcome for twelve patients with a rerupture and seven patients with a deep infection at a mean of 4.1 years after the initial treatment.Results: The annual incidence of reruptures (per 100,000 inhabitants) increased from 0.25 in 1979-1990 to 1.0 in 1991-2000, and that of deep infections increased from 0 in the 1980s to 0.63 in the 1990s. The ratio of complications to primary ruptures did not change. The patients with deep infections were significantly older, received corticosteroid medication more often, had sustained the tendon injury during everyday activities more often, and had a longer delay before treatment than the patients with simple reruptures. At 4.1 years after the primary treatment, eight of twelve patients in the rerupture group had a satisfactory clinical outcome and the overall average isokinetic plantar flexion strength deficit in that group was only 10%. In contrast, two of the patients in the infection group had a fair clinical outcome and five had a poor outcome, and the average isokinetic plantar flexion strength deficit in that group was 35%.Conclusions: The incidence of Achilles tendon reruptures and deep infections has increased. The outcome is satisfactory after a simple rerupture without infection, but the results after a deep infection are often devastating.

Comparison of remifentanil and nitrous oxide in labour analgesia

Background:  We compared the efficacy and side‐effects of remifentanil with those of nitrous oxide during the first stage of labour.

Five-year outcome of laparoscopic and Lichtenstein hernioplasties

Background: Laparoscopic hernia repair has been proved superior to open repairs in terms of short-term results, but long-term results of laparoscopic and open mesh repairs have been lacking until recently. Methods: A total of 123 patients were randomly allocated to two treatment groups comparing laparoscopic and Lichtenstein hernioplasties in three separate trials. The first and second trials compared small and large mesh used in transabdominal preperitoneal repairs, and the third study compared totally extraperitoneal hernioplasty with the Lichtenstein operation. A 5-year follow-up visit was scheduled to assess recurrencies, symptoms, and patient satisfaction. Results: For the follow up evaluation, 121 (98.4%) of the patients were reached. There were five hernia recurrences in the laparoscopic group (small mesh) and two in the Lichtenstein group (difference, 5%; 95% confidence interval, −4–13%; p = 0.3). One patient who underwent the transabdominal preperitoneal polypropylene procedure underwent reoperation 3 years later because of dense small bowel adhesions at the inguinal surgical site. Chronic groin pain was more common after open operation (0 vs 4) patients (difference 7%; confidence interval, −0.4–16%; p = 0.04). Ten patients (16%) in the laparoscopic group and 12 (20%) in the open group reported discomfort or pain at the surgical site. Conclusions: Both laparoscopic and Lichtenstein hernioplasties have a low risk for hernia recurrence if proper mesh size is used. The patients who undergo hernioplasty with open mesh hernioplasty seem to experience chronic symptoms and pain more often than those managed with the laparoscopic procedure.

Epidemiology of Achilles tendon ruptures: Increasing incidence over a 33-year period

We investigated the epidemiology of total Achilles tendon ruptures and complication rates after operative and nonoperative treatments over a 33‐year period in Oulu, Finland. Patients with Achilles tendon ruptures from 1979 to 2011 in Oulu were identified from hospital patient records. Demographic data, treatment method, and complications were collected retrospectively from medical records. Overall and sex‐ and age‐specific incidence rates were calculated with 95% confidence intervals (CIs). The overall incidence per 100 000 person‐years increased from 2.1 (95% CI 0.3–7.7) in 1979 to 21.5 (95% CI 14.6–30.6) in 2011. The incidence increased in all age groups. The mean annual increase in incidence was 2.4% (95% CI 1.3–4.7) higher for non‐sports‐related ruptures than for sports‐related ruptures (P = 0.036). The incidence of sports‐related ruptures increased during the second 11‐year period whereas the incidence of non‐sports‐related ruptures increased steadily over the entire study period. Infection was four times more common after operative treatment compared with nonoperative treatment, re‐rupture rates were similar. The incidence of Achilles tendon ruptures increased in all age groups over a 33‐year period. Increases were mainly due to sports‐related injuries in the second 11‐year period and non‐sports‐related injuries in the last 11‐year period.

Progression of human aortic valve stenosis is associated with tenascin-C expression

OBJECTIVES We sought to assess tenascin-C (TN-C) expression and its possible pathobiological impact in human aortic valve stenosis. BACKGROUND Tenascin-C, a large extracellular matrix glycoprotein, has lately been increasingly connected to cardiovascular pathologies. As TN-C is a multifunctional protein implicated in cell proliferation, migration and differentiation, we investigated the pattern of its expression in diseased human aortic valves. METHODS Fifty-five tricuspid, non-rheumatic stenotic aortic valves were collected from patients undergoing aortic valve replacement, and the controls consisted of four normal valves from individuals who had suffered traumatic death and one from a patient operated on because of a noncalcified purely regurgitant valve. A monoclonal mouse antibody to human TN-C (143DB7) was used as the primary antibody in immunostaining. To study the source of TN-C messenger RNA synthesis, some tissue samples were also examined using in situ hybridization. In order to identify smooth muscle cell differentiation, commercially available antibodies against alpha-smooth muscle actin were used, and immunophenotypic analysis of inflammatory cells was carried out by using the monoclonal mouse antibodies UCHL-1, L26 and PGM-1. RESULTS In normal valves, TN-C expression was associated with the basement membrane beneath the endothelial cells, whereas stenotic valves showed no such expression but rather immunoreactivity in the deeper layers of the valves. This reactivity was associated with the characteristics typical of the stenosing process and the increased mechanical loading caused by hypertension. CONCLUSIONS We hypothesize that the overexpression of TN-C in stenotic human aortic valves may emphasize that this disease is an active rather than a degenerative process.

Increasing numbers of ureteric injuries after the introduction of laparoscopic surgery

Objective. There is an impression that ureteric injuries have become more common during the past decade, and therefore this study aimed to determine the incidence, aetiology, features, treatment and outcomes of ureteric injuries over an extended period. Material and methods. Records of patients treated for ureteric injury in 1986–2006, divided into three 7-year periods, were reviewed retrospectively. The numbers of open and laparoscopic gynaecological, surgical and endourological operations were ascertained. Results. All 72 ureteric injuries recorded were iatrogenic, being diagnosed in 60 females and 11 males (mean age 52 years). Only five injuries occurred during the first 7-year period (1986–1992), but the incidence was markedly higher during the following two 7-year periods, 28 (1993–1999) and 39 (2000–2006), respectively. The injuries were mostly secondary to gynaecological procedures (64%) or general surgery (25%). Only 11% occurred in association with a urological procedure. The cause was mostly laparoscopic (56%) or open surgery (33%), and the injury was in most cases located in the lower ureter (89%). The diagnosis was usually delayed (in 79%), with a median time to diagnosis of 6 days. The injuries were managed by ureteroneocystostomy (49%), a ureteral stent (19%) or end-to-end anastomosis (12%). The complication rate was 36%. Conclusions. Iatrogenic ureteric injuries have increased markedly during the past two decades. Gynaecological laparoscopic procedures account for more than half of the injuries, and the most common location is the lower ureter. Most injuries are treated by ureteroneocystostomy, but endourological treatment yields acceptable results. To improve the management of ureteric injury there must be a high index of suspicion, especially during laparoscopic operations.

Disability in end-stage knee osteoarthritis

Objective. To examine the attributes of disability in end-stage knee osteoarthritis (OA) by analyzing the relationships between self-reported disability and objectively measured physical function after controlling pain, personal characteristic factors, and pathophysiological factors. Methods. The present study adopted a cross-sectional design. The subjects (n=88, aged 60–80 years) were scheduled for primary unilateral total knee arthroplasty (TKA) due to knee OA. Self-reported disability and pain were measured with the Western Ontario and McMaster Universities OA Index (WOMAC) and the RAND 36-item Health Survey 1.0 (RAND-36). Physical performance tests included a 15-m walk test and stair performance. Knee isometric muscle strength was measured. A clinical examination included analyses of comorbidity, body mass index (BMI), and a detailed knee examination: The flexion range of motion (ROM) was measured; the presence of varus/valgus malalignments and antero-posterior laxity was assessed. Radiographs were analyzed with the Kellgren-Lawrence grading scale. Results. In the linear regression model the WOMAC pain score, antero-posterior laxity of the knee, age, and BMI accounted for 54.8% of the variance in the WOMAC function score. In the bivariate analyses the WOMAC function score had a positive correlation with the 15-m walk (rs=0.32, p=0.003), stairs up (rs=0.40, p=0.001), and stairs down (rs=0.38, p=0.001) tests, and a negative correlation with RPT extension (rs=−0.45, p < 0.001) and RPT flexion (rs=−0.39, p=0.001) of the affected side and RPT flexion (rs=−0.39, p <0.001) of the contralateral side. The results of the physical performance tests also correlated with the RAND-36 Physical function (PF) score. Comorbid diseases and pain deteriorated the results of the physical performance tests and self-reported disability. Female gender deteriorated the results of the physical performance tests and the RAND-36 PF, but not the WOMAC function score. Malalignments, restriction in the flexion ROM of the knee, and the radiologic severity of knee OA did not affect self-reported disability. Conclusion. Pain, BMI, and antero-posterior laxity of the knee joint were major attributes of self-reported disability. The negative effect of comorbid diseases and female gender on health-related quality of life was significant. The results of objectively measured physical performance tests correlated with self-reported disability.

Prebiopsy Multiparametric Magnetic Resonance Imaging for Prostate Cancer Diagnosis in Biopsy-naive Men with Suspected Prostate Cancer Based on Elevated Prostate-specific Antigen Values: Results from a Randomized Prospective Blinded Controlled Trial

BACKGROUND Multiparametric magnetic resonance imaging (MP-MRI) may improve the detection of clinically significant prostate cancer (PCa). OBJECTIVE To compare MP-MRI transrectal ultrasound (TRUS)-fusion targeted biopsy with routine TRUS-guided random biopsy for overall and clinically significant PCa detection among patients with suspected PCa based on prostate-specific antigen (PSA) values. DESIGN, SETTING, AND PARTICIPANTS This institutional review board-approved, single-center, prospective, randomized controlled trial (April 2011 to December 2014) included 130 biopsy-naive patients referred for prostate biopsy based on PSA values (PSA <20 ng/ml or free-to-total PSA ratio ≤0.15 and PSA <10 ng/ml). Patients were randomized 1:1 to the MP-MRI or control group. Patients in the MP-MRI group underwent prebiopsy MP-MRI followed by 10- to 12-core TRUS-guided random biopsy and cognitive MRI/TRUS fusion targeted biopsy. The control group underwent TRUS-guided random biopsy alone. INTERVENTION MP-MRI 3-T phased-array surface coil. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was the number of patients with biopsy-proven PCa in the MP-MRI and control groups. Secondary outcome measures included the number of positive prostate biopsies and the proportion of clinically significant PCa in the MP-MRI and control groups. Between-group analyses were performed. RESULTS AND LIMITATIONS Overall, 53 and 60 patients were evaluable in the MP-MRI and control groups, respectively. The overall PCa detection rate and the clinically significant cancer detection rate were similar between the MP-MRI and control groups, respectively (64% [34 of 53] vs 57% [34 of 60]; 7.5% difference [95% confidence interval (CI), -10 to 25], p=0.5, and 55% [29 of 53] vs 45% [27 of 60]; 9.7% difference [95% CI, -8.5 to 27], p=0.8). The PCa detection rate was higher than assumed during the planning of this single-center trial. CONCLUSIONS MP-MRI/TRUS-fusion targeted biopsy did not improve PCa detection rate compared with TRUS-guided biopsy alone in patients with suspected PCa based on PSA values. PATIENT SUMMARY In this randomized clinical trial, additional prostate magnetic resonance imaging (MRI) before prostate biopsy appeared to offer similar diagnostic accuracy compared with routine transrectal ultrasound-guided random biopsy in the diagnosis of prostate cancer. Similar numbers of cancers were detected with and without MRI. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01357512.

Evidence for an altered balance between matrix metalloproteinase-9 and its inhibitors in calcific aortic stenosis

BACKGROUND Recently, aortic valve stenosis has been demonstrated to exhibit increased expression of certain matrix metalloproteinases (MMPs), and this has relevantly raised the question about possible interdependency between these and their tissue inhibitors. We sought to assess the expression of elastolytic MMPs and their inhibitors (TIMPs) in nonrheumatic aortic stenosis. METHODS The study comprised 30 stenotic and six noncalcified human aortic valves. To measure the expression levels and the amount and molecular forms of gelatinases (MMP-2, MMP-9) and TIMPs (1, 2), in situ hybridization, gelatin zymography, and reverse zymography were carried out. Antielastin staining by a monoclonal BA-4 antibody was performed to investigate the changes of one of the main substrates of these MMPs, and to substantiate the nature of the putative MMP- synthesizing cell. The cases were also immunostained with an antibody to alpha-smooth muscle actin. Inflammatory cell characterization was managed by monoclonal mouse antibodies (UCHL-1, L26, and PGM-1). RESULTS Compared with the controls, the calcific valves showed increased mRNA expression and activation of MMP-9, and this was associated with typical characteristics of valve disease. MMP-2 mRNA production was rare, but proMMP-2 protein was detected in all valves. In agreement with the interdependency between MMP-9 and its inhibitors, a suggestive imbalance came out in diseased valves. CONCLUSIONS The disproportion between MMP-9 and its tissue inhibitors may favor a persistent MMP activation state within the calcific valve and likely contribute to the valvular remodeling process in the setting of developing aortic stenosis.