Vesa Savolainen

Internal fixation of proximal humeral fractures with a locking compression plate: a retrospective evaluation of 72 patients followed for a minimum of 1 year.

Background Proximal humeral fractures, particularly in osteoporotic patients, remain an unsolved problem as regards the durability of the osteosynthesis. The AO/ASIF group has developed a new technique which aims to preserve the biological integrity of the humeral head and secures the reduction using multiple locking screws with angular stability (Philos), thus allowing an early mobilization. Patients and outcome We retrospectively reviewed the complications and functional outcome after a minimum follow-up of 1 year in 72 patients treated with this new method. 2 fractures failed to unite, and 3 patients developed an avascular necrosis of the humeral head. In addition, 2 implant failures were observed due to a technical error. According to the Constant score, the functional outcome was acceptable even in elderly patients. Interpretation The Philos method appears to be safe and can be recommended for the treatment of proximal humeral fractures in patients with poor bone quality.

Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail: A RANDOMISED STUDY COMPARING POST-OPERATIVE REHABILITATION

We treated 108 patients with a pertrochanteric femoral fracture using either the dynamic hip screw or the proximal femoral nail in this prospective, randomised series. We compared walking ability before fracture, intra-operative variables and return to their residence. Patients treated with the proximal femoral nail (n = 42) had regained their pre-operative walking ability significantly (p = 0.04) more often by the four-month review than those treated with the dynamic hip screw (n = 41). Peri-operative or immediate post-operative measures of outcome did not differ between the groups, with the exception of operation time. The dynamic hip screw allowed a significantly greater compression of the fracture during the four-month follow-up, but consolidation of the fracture was comparable between the two groups. Two major losses of reduction were observed in each group, resulting in a total of four revision operations. Our results suggest that the use of the proximal femoral nail may allow a faster post-operative restoration of walking ability, when compared with the dynamic hip screw.

Sling Compared with Plate Osteosynthesis for Treatment of Displaced Midshaft Clavicular Fractures A Randomized Clinical Trial

BACKGROUNDnFew randomized controlled trials have compared operative with nonoperative treatment of clavicular fractures.nnnMETHODSnPatients with displaced midshaft clavicular fractures were randomized either to nonoperative treatment with a sling or to operative treatment with a stainless steel 3.5-mm reconstruction plate. Outcome measures were the Constant shoulder score, DASH (Disabilities of the Arm, Shoulder and Hand) score, pain, fracture-healing, and complications. The null hypothesis was that the Constant and DASH scores would not differ between the groups at the one-year follow-up evaluation.nnnRESULTSnIn accordance with the power analysis, we included sixty patients in the study; thirty-two were randomized to the nonoperative group and twenty-eight to the operative group. We found no difference in the Constant score (p = 0.75), the DASH score (p = 0.89), or pain (p = 0.98) between the groups at the one-year follow-up evaluation. All fractures in the operative group healed, but six nonunions (24%) occurred in the nonoperative group.nnnCONCLUSIONSnOne year after a displaced midshaft clavicular fracture, nonoperative treatment resulted in a higher nonunion rate but similar function and disability compared with operative treatment.

Femoral shaft medialisation and neck-shaft angle in unstable pertrochanteric femoral fractures

We analysed the time-dependent mean changes in the femoral neck length, neck-shaft angle and hip offset in a randomised study comprising 48 patients who were treated with the dynamic hip screw (DHS) or the proximal femoral nail (PFN) for an unstable intertrochanteric femoral fracture. As a consequence of fracture compression, the mean post-operative neck length was significantly shorter in patients treated with the DHS. During the first 6 weeks after the operation, a mean decrease of 4.6° was observed in the neck-shaft angle, but there was not a significant difference between the treatment groups. The radiographic measures remained virtually unaffected during the interval from 6 weeks to 4 months in both groups. When the operated hip was compared to the opposite hip, patients who had received the DHS showed significantly greater medialisation of the femoral shaft at 4 months than those treated with the PFN. We thus recommend that unstable intertrochanteric fractures should be initially reduced in a slight valgus position in order to achieve an outcome after healing that is as normal as possible. As a result of differences in operative technique and implant stability, the PFN may be superior to the DHS in retaining the anatomical relations in the hip region in unstable intertrochanteric fractures.RésuméNous avons analysé les modifications, en fonction du temps, des valeurs moyennes de la longueur du col fémoral, de l’angle cervico-diaphysaire et du bras de levier de la hanche dans une étude randomisée qui comprenait 48 malades traités avec une Vis Dynamique (DHS) ou un Clou Fémoral Proximal (PFN) aprés une fracture intertrochantérienne instable. Par suite de la compression de la fracture, la longueur du col était nettement plus courte chez les malades traités avec une DHS. Pendant les premières six semaines après l’opération, une baisse moyenne de 4.6° de l’angle cervico-diaphysaire a été observée mais il n’y avait pas de différence notable entre les groupes de traitement. Les mesures radiographiques sont restées pratiquement non affectées pendant l’intervalle de six semaines à quatre mois dans les deux groupes. Comparé à la hanche opposée, les malades qui avaient reçu une DHS ont montré à 4 mois une nettement plus grande médialisation de la diaphyse que ceux traités avec le PFN. Nous recommandons que ces fractures intertrochantériennes instables soient réduites en léger valgus pour avoir une situation aussi normale que possible après consolidation. Par suite de différences dans la technique opératoire et dans la stabilité de l’implant, le PFN semble supérieur au DHS pour rétablir l’anatomie de la région de la hanche dans les fractures intertrochantériennes instables.

Factors predisposing to dislocation of the Thompson hemiarthroplasty: 22 dislocations in 338 patients

In a series of 338 patients, we have retrospectively analyzed technical and anatomical factors, which may predispose to a dislocation of the Thompson hemiprosthesis. 22 patients (7%) had at least 1 dislocation during the 6-month follow-up. The most significant independent factor predisposing to dislocation was the use of a posterior approach (dislocation rate 16%). We examined the radiographs and data on operations in the 22 patients, using 79 random patients without dislocation as controls. Factors correlating with an increase in the incidence of dislocation were the length of the residual femoral neck > 0.5 cm in short patients (< 165 cm), and considerable change in the postoperative offset of the hip. Acetabular measurements showed no correlation to the dislocation. Our findings suggest that the main factors predicting dislocation are technical and not related to anatomical measurements.

Arthrosis of glenohumeral joint after arthroscopic Bankart repair: a long-term follow-up of 13 years

HYPOTHESISnThe purpose of the study was to establish radiologic and clinical occurrence of glenohumeral arthrosis after arthroscopic Bankart repair.nnnMATERIALS AND METHODSnBetween January 1994 and December 1998, an arthroscopic Bankart repair was performed in 187 patients at our institution. We were able to assess clinical and radiologic glenohumeral arthrosis in 72 of the 101 patients who met the inclusion criteria (74 shoulders) (71%) after a 13-year follow-up. An additional 9 patients were interviewed by telephone. Radiologic arthrosis was evaluated with the Samilson-Prieto classification and clinical arthrosis with an arthrosis-specific quality-of-life questionnaire (Western Ontario Osteoarthritis of the Shoulder test). In addition, functional impairment was assessed with the Constant score and subjective satisfaction with a questionnaire.nnnRESULTSnRadiologic arthrosis was diagnosed in 50 of 74 shoulders (68%), with 40 (80%) of them classified as mild. The mean score on the Western Ontario Osteoarthritis of the Shoulder questionnaire was 280 points (85% of the best possible score), which is considered relatively good. The mean Constant score was 78 points, and 75% of the patients were extremely satisfied or satisfied with the final results of operative treatment.nnnDISCUSSIONnThe radiologic evaluation and self-assessment of the patients imply that the incidence of glenohumeral arthrosis after arthroscopic Bankart repair is quite common but the symptoms are generally mild and comparable to nonoperative treatment.nnnCONCLUSIONnArthrosis rarely causes more than minor subjective symptoms or a minor objectively perceived disadvantage during 13 years follow-up.

Surgical treatment of Rockwood grade-V acromioclavicular joint dislocations 50 patients followed for 15-22 years

Background and purpose Long-term outcome after surgery for grade-V acromioclavicular joint dislocation has not been reported. We performed a retrospective analysis of functional and radiographic outcome 15–22 years after surgery. Patients and methods We examined 50 patients who were treated at our hospital between April 1985 and December 1993. Various methods of stabilization were used: K-wires (n = 36), 4.5-mm screw (n = 12), or biodegradable screw (n = 2). Osteosynthesis material was removed after 6–8 weeks. Mean follow-up time was 18 (15–22) years. Outcomes were assessed with the Constant shoulder (CS) score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, the simple shoulder test (SST), the Copeland shoulder impingement test, the cross-arm test, pain, stability of the AC joint, and complications. From radiographs, we evaluated AC and glenohumeral (GH) arthrosis, osteolysis of the lateral clavicle, and alignment of the clavicle with the acromion. Results Mean values were 90 (75–100) in CS score, 5.1 (0–41) in DASH score, and 11 (2–12) in SST. There was no statistically significant difference in CS score between the injured shoulder and the uninjured shoulder. The AC joint was clinically stable in 42 patients. In 38 patients, the clavicle alignment with the acromion was normal in radiographs. Lateral clavicle osteolysis (10 patients) appeared to be associated with permanent AC joint dislocation. Interpretation Surgery with a temporary fixation for acute grade-V AC joint dislocation leads to successful long-term functional results. Only minor disability occurred in some patients.

Surgical treatment of chronic acromioclavicular joint dislocation with autogenous tendon grafts.

BackgroundConservative treatment of acromioclavicular (AC) joint dislocation is not always successful. A consequence of persistent AC joint dislocation may be chronic pain and discomfort in the shoulder region as well a sensation of constant AC joint instability and impaired shoulder function. Stabilization of the AC joint may reduce these sequels.Materials and methodsDue to chronic AC joint dislocation, 39 patients in our hospital underwent coracoclavicular (CC) ligament reconstruction with autogenous semitendinosus and gracilis tendons between May 2005 and April 2011. We examined 25 patients after a mean of 4.2xa0years. The outcomes were Constant shoulder Score (CS), Disabilities of the Arm, Shoulder and Hand (DASH), pain (Visual Analog Scale, VAS), cross-arm test, stability of the AC joint, and complications. The follow-up visits included anteroposterior and axillary radiographs.ResultsMean CS was 83 in the injured shoulder and 91 in the uninjured shoulder (pu2009=u20090.002). Mean DASH was 14. In 14 patients, the AC joint was clinically stable; pain was minor. In radiographs, osteolysis of the lateral clavicle and tunnel widening were markedly common. Fracture of the coracoid process occurred in 5 patients, and 3 suffered a fracture of the clavicle; 2 had a postoperative infection.ConclusionsAnatomic reconstruction of CC ligaments showed a moderate subjective outcome at the 4-year follow-up. After surgery, almost half the AC joints failed to stabilize. Lateral clavicle osteolysis and tunnel widening were notably common complications.

Hybrid external fixation in treatment of proximal tibial fractures: a good outcome in AO/ASIF type-C fractures

IntroductionThe treatment of proximal tibial fractures is often challenging, and internal fixation is occasionally associated with problems in wound healing due to frequently co-existing soft tissue injuries. External fixation of these fractures have yielded satisfactory results, but some studies have reported problems in the achievement and maintenance of fracture reduction. The purpose of the present study was to evaluate the performance of a hybrid external fixator in the treatment of different types of proximal tibial fractures.Materials and methodsThirty-three proximal tibial fractures, of which 20 were high energetic, were treated with a hybrid external fixator (Tenxor® Strker-Howmedica) in the acute phase. Fracture categorisation was done according to AO/ASIF, and the reduction was performed most often by closed means or through mini-open reduction (26/78.8%). The patients were followed up to an average of 12.7xa0months (range 10–22) and were evaluated with radiographs and clinical examinations.ResultsFive AO/ASIF type-C intraarticular fractures had a poor postoperative reduction, and were thus treated with internal fixation in a second operation. Of the remaining 28 patients, local and transient pin tract infection was observed in seven patients, and one had septic arthritis of the knee. All 13 C1 and five of six C2/C3 fractures united in mean time of 15.1xa0weeks, whereas three of nine type-A fractures failed to unite, albeit an adequate reduction, and needed a second operation (odds ratio 11.4, 95% CI 1.0–143, compared with type-C fractures). For the remaining six type-A fractures, the mean healing time was 24xa0weeks (mean difference 8.9, 95% CI 6–12xa0weeks compared with type-C fractures). Age over 48 and the presence of an open fracture, but not fracture type, gender, or the level of injury energy, correlated to a poor subjective outcome.ConclusionsThe hybrid external fixation method we have used is safe, and type-C1 fractures are particularly suitable to be treated with this method. However, even C2/C3 fractures may be candidates for this method, but a meticulous fracture reduction should be performed. Type-A fractures are liable to healing problems when the fixator is used as a rigid complex.

Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial

Abstract Objective To assess the efficacy of arthroscopic subacromial decompression (ASD) by comparing it with diagnostic arthroscopy, a placebo surgical intervention, and with a non-operative alternative, exercise therapy, in a more pragmatic setting. Design Multicentre, three group, randomised, double blind, sham controlled trial. Setting Orthopaedic departments at three public hospitals in Finland. Participants 210 patients with symptoms consistent with shoulder impingement syndrome, enrolled from 1 February 2005 with two year follow-up completed by 25 June 2015. Interventions ASD, diagnostic arthroscopy (placebo control), and exercise therapy. Main outcome measures Shoulder pain at rest and on arm activity (visual analogue scale (VAS) from 0 to 100, with 0 denoting no pain), at 24 months. The threshold for minimal clinically important difference was set at 15. Results In the primary intention to treat analysis (ASD versus diagnostic arthroscopy), no clinically relevant between group differences were seen in the two primary outcomes at 24 months (mean change for ASD 36.0 at rest and 55.4 on activity; for diagnostic arthroscopy 31.4 at rest and 47.5 on activity). The observed mean difference between groups (ASD minus diagnostic arthroscopy) in pain VAS were −4.6 (95% confidence interval −11.3 to 2.1) points (P=0.18) at rest and −9.0 (−18.1 to 0.2) points (P=0.054) on arm activity. No between group differences were seen between the ASD and diagnostic arthroscopy groups in the secondary outcomes or adverse events. In the secondary comparison (ASD versus exercise therapy), statistically significant differences were found in favour of ASD in the two primary outcomes at 24 months in both VAS at rest (−7.5, −14.0 to −1.0, points; P=0.023) and VAS on arm activity (−12.0, −20.9 to −3.2, points; P=0.008), but the mean differences between groups did not exceed the pre-specified minimal clinically important difference. Of note, this ASD versus exercise therapy comparison is not only confounded by lack of blinding but also likely to be biased in favour of ASD owing to the selective removal of patients with likely poor outcome from the ASD group, without comparable exclusions from the exercise therapy group. Conclusions In this controlled trial involving patients with a shoulder impingement syndrome, arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy at 24 months. Trial registration Clinicaltrials.gov NCT00428870.