Yngvar Krukhaug

Lateral ligament injuries of the knee

Abstract Between 1982 and 1994 28 patients were treated for acute lateral knee ligament injuries; 25 patients, with a median age of 25.5 (range 16–75) years at injury, appeared for follow-up. Seven patients had isolated injury of the lateral collateral ligament/capsular structures, the remaining 19 patients had concomitant ligament injuries in the knee. Eight patients were treated conservatively, 1 with plaster immobilization and 7 with early mobilization. Eighteen patients underwent surgery, 17 of these within 3 weeks of injury. Repair/reconstruction of the cruciate ligaments was done at the same time as the lateral collateral ligament repair in 10 patients. At follow-up after a median of 7.5 years (range 6 months to 13 years), 11 had no varus instability, 7 had 1+, 5 had 2+, and 2 patients had 3+ varus instability. All patients with a final result of 2+ or 3+ had combined ligament injuries. The surgically treated lateral collateral ligament injuries all had a primary instability of 2+ or more. These patients showed an improvement in varus instability from a mean of 2.83+ preoperatively to a mean of 1.17+ postoperatively. Two-thirds of the surgically treated patients were stable or had a 1+ instability at follow-up. One conservatively treated patient with a 2+varus instability and 1 with 1+ showed no improvement. Five conservatively treated patients with initial varus instability of 1+ were stable at follow-up. One patient with a 1+ varus instability had anterior cruciate ligament (ACL) rupture. He had a primary ACL reconstruction without lateral repair. He had no varus instability at follow-up. Our study supports the notion that operation performed at an early stage in fresh injuries with a varus instability of 2+ or more gives improved stability as a final result. Conservative treatment may not be expected to give an improved stability, but is sufficient in mild varus instability (1+) without additional cruciate ligament injuries.

Results of 189 wrist replacements. A report from the Norwegian Arthroplasty Register.

Background and purpose There is very little literature on the long-term outcome of wrist replacements. The Norwegian Arthroplasty Register has registered wrist replacements since 1994. We report on the total wrist replacements and their revision rates over a 16-year period. Material and methods 189 patients with 189 primary wrist replacements (90 Biax prostheses (80 of which were cementless), 23 cementless Elos prostheses, and 76 cementless Gibbon prostheses), operated during the period 1994–2009 were identified in the Norwegian Arthroplasty Register. Prosthesis survival was analyzed using Cox regression analyses. The 3 implant designs were compared and time trends were analyzed. Results The 5-year survival was 78% (95% CI: 70–85) and the 10-year survival was 71% (CI: 59–80). Prosthesis survival was 85% (CI: 78–93) at 5 years for the Biax prosthesis, 77% (CI: 30–90) at 4 years for the Gibbon prosthesis, and 57% (CI: 33–81) at 5 years for the Elos prosthesis. There was no statistically significant influence of age, diagnosis, or year of operation on the risk of revision, but females had a higher revision rate than males (RR = 3, CI: 1–7). The number of wrist replacements performed due to osteoarthritis increased with time, but no such change was apparent for inflammatory arthritis. Interpretation The survival of the total wrist arthroplasties studied was similar to that in other studies of wrist arthroplasties, but it was still not as good as that for most total knee and hip arthroplasties. However, a failed wrist arthroplasty still leaves the option of a well-functioning arthrodesis.

The results of 479 thumb carpometacarpal joint replacements reported in the Norwegian Arthroplasty Register

In this study we report the results of thumb carpometacarpal (CMC) joint replacements in the Norwegian population over a 17-year period. In total, 479 primary replacements performed from 1994 to 2011 were identified in the Norwegian Arthroplasty Register. Implant survival and risk of revision were analyzed using Cox regression analyses. Four different implant designs were compared and time trends were analyzed. The overall 5 and 10 year survivals were 91% and 90%, respectively. The newer metal total arthroplasties did not outperform the older silicone and mono-block implants. At 5 years, the implant survival ranged from 90% to 94% for the different implant brands. Gender, age, and diagnosis did not influence the risk of revision. The incidence of thumb CMC joint replacement did not change during the study period. Despite relatively satisfactory implant survivorship in our register study, current evidence does not support widespread implementation of thumb CMC replacements.

Dynamic Compared with Static External Fixation of Unstable Fractures of the Distal Part of the Radius: A Prospective, Randomized Multicenter Study

BACKGROUND External fixation is an established method of treating certain types of distal radial fractures. We have designed a dynamic external fixator to treat these fractures. The purpose of the present study was to compare this device with current static bridging external fixators in terms of anatomical and functional results. METHODS We conducted a prospective randomized study to compare the radiographic and clinical results of dynamic external fixation with those of static external fixation for the treatment of seventy unstable distal radial fractures. Mobilization of the wrist was begun in the dynamic fixator group on the day after surgery. The external fixation frames were kept in place for a mean of six weeks. The patients were assessed clinically and radiographically at the time of removal of the fixator and at three, six, and twelve months. RESULTS Dynamic fixation resulted in a significantly better restoration of radial length at all follow-up visits in comparison with static fixation. There were no significant differences in radial tilt or radial inclination between the two groups. Wrist flexion, radial deviation, and pronation-supination were regained significantly faster in the dynamic fixator group. Wrist extension was significantly better in the dynamic fixator group in comparison with the static fixator group at all follow-up times. Self-evaluation with use of the Disabilities of the Arm, Shoulder and Hand score and a visual analog pain score demonstrated no significant differences between the two groups at the time of the latest follow-up. Superficial pin-track infections were significantly more common in the dynamic external fixator group than in the static fixator group. CONCLUSIONS Continuous dynamic traction with a dynamic external fixator compares favorably with the use of static external fixators for the treatment of unstable fractures of the distal part of the radius.

Corrective osteotomy for malunited extra-articular fractures of the distal radius: a follow-up study of 33 patients.

We present a series of 33 consecutive patients treated with lengthening osteotomy due to malunited extra-articular fractures of the distal radius. Thirty-one patients were able for long-term follow-up a median (range) of seven (2–20) years after the procedure. The indication for reconstruction was mainly impaired function of the wrist. Both the anatomy and function were improved significantly postoperatively. The median radial length improved 5 mm, the radial tilt 25°, and the radial inclination improved 9°. The median improvement of forearm supination was 20°, pronation 10°, dorsal wrist flexion 10°, and volar flexion 20°. Twenty-two of 29 patients (76%) rated the functional results as good or excellent. The functional results were significantly better postoperatively, but the results were still better on the uninjured side. The grip strength on the operated hand was 82% of the uninjured hand, and the median postoperative DASH-score was 21. In five patients the graft resorbed (one fracture of the plate) and needed reoperation. All eventually healed and the anatomical and functional results were good. Another patient had symptomatic osteoarthrosis and later had a full wrist fusion. We conclude that every effort should be made to prevent malunion in the treatment of distal radius fractures, because even after anatomical correction, function is not restored fully in all patients.

Experience with the AO Pi-plate for displaced intra-articular fractures of the distal radius.

We have used open reduction and internal fixation (ORIF) with the AO π-plate in 32 displaced, intra-articular fractures of the distal radius. The indication was a displaced intra-articular fracture with a step-off of more than 1 mm and a gap between fragments of more than 3 mm, judged from the primary computed tomograms (CT). All fractures were classified as AO type C3. Twenty-nine patients were followed-up after a mean of 23 (9-46) months. The dorsal tilt, the radial length, the radial inclination, the articular step-off, and the intra-articular gap between fragments were substantially improved postoperatively. All the patients had excellent or good extra-articular and intra-articular alignment. Two patients had reduced extension power of the first finger. Seventeen patients had Disability of the arm, shoulder, and hand (DASH) scores of less than 10 points, five had scores between 11 and 20, three between 21 and 30, three between 31 and 40, and one patient had a score of 65 points. Complications occurred in two patients: one had a painful amputation neuroma of the superficial radial nerve, and one developed adhesions of the flexor tendons of the second and third fingers because the screws were too long and had penetrated the tendon sheaths. We conclude that the AO π-plate is an excellent option for the most comminuted fractures of the distal radius.

Females report higher postoperative pain scores than males after ankle surgery

Graphical Abstract Abstract Objectives The majority of patients experience moderate-to-intense pain following ankle surgery. Early, adequate treatment of postoperative pain is desirable for optimal pain relief, which in turn may facilitate optimal pulmonary function, normal respiration pattern, rehabilitation and prevention of a chronic pain condition. In this retrospective study, we aimed to identify possible predictors of moderate-to-intense postoperative pain while in the Post Anaesthesia Care Unit (PACU) in patients operated for ankle fractures. Materials and methods Social demographics and clinical characteristics from admission throughout the stay in the PACU were collected from the hospital patient record system in retrospect. Pain was assessed using a Visual Analogue Scale (VAS) or a verbal Numeric Rating Scale (vNRS). A VAS/vNRS score 4–6 was classified as moderate and 7–10 as intense pain. Other factors which were investigated were time from ankle fracture to surgery, anaesthetic procedure, pre-, per- and postoperative medical treatment, radiological classification, complexity of fracture, operative technique, and time using tourniquet procedure. Results Data from 336 patients who underwent surgery to repair an ankle fracture between January 2009 and December 2010 were analysed. None of the following variables had a statistically significant effect on pain; age, weight, smoking, timeframe from fracture to operation, type of anaesthesia, opioids given peroperatively, complexity of the fracture, operation technique or tourniquet inflation procedure. Female sex predicted moderate-to-intense postoperative pain in the PACU with odds ratio 2.31 (95% confidence interval 1.39–3.86), P = 0.001. As far as we know, this is the first study to show a sex difference in reporting pain in the first hours after surgery for ankle fracture. Conclusion Female patients operated for ankle fracture report higher pain-intensity-score than male patients while in the PACU. Implications Our findings suggest that treatment strategies to prevent high peaks of pain should particularly target women operated for an ankle fracture.

Treatment of distal radius fractures

BACKGROUND In light of the Norwegian Orthopaedic Associations wish to prepare guidelines for treatment of distal radius fractures, we have reviewed the knowledge base for the provision of such treatment. METHOD The paper is based on systematic reviews of treatment of distal radius fractures from literature search in the following databases: the Cochrane Library, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE Cochrane), the Health Technology Assessment (HTA) database, PreMedline, Medline and Embase. RESULTS There is evidence for recommending percutaneous pinning of unstable, dorsally displaced distal radius fractures rather than conservative treatment, but which pinning method is best remains uncertain. There is also documentation to support the use of external fixation rather than conservative treatment. There is insufficient documentation available to draw conclusions regarding the relative efficacy of the various methods of external fixation, but external fixation in combination with adjuvant pinning of the fracture fragment enhances the result compared to external fixation alone. The evidence indicates that plates may enhance functional short-term results for unstable distal radius fractures compared to external fixation. INTERPRETATION There is evidence in support of differentiated treatment of distal radius fractures. However, many questions remain unanswered, and good prospective, randomised multi-centre trials are needed.

Different osteosyntheses for Colles' fracture: A mechanical study in 42 cadaver bones

Background and purpose In recent years several different plate designs for internal fixation of fractures of the distal radius have been developed. However, few biomechanical studies have been performed to compare these new implants. The purpose of this study was to compare the mechanical properties of 5 different commercially available plates (3 volar and 2 dorsal) with standard K-wire fixation using a distal radial cadaver model. Material and methods 42 human radial bones from 26 cadavers were included. The bone mineral density (BMD) was measured by DEXA in all bones, and the radial bones were assigned to 6 equiv alent groups based on bone density and total amount of mineral. A distal radial osteotomy was done and a dorsal 30-degree wedge of bone was removed. 1 K-wire fixation group and 5 plate groups were tested for rigidity, yield load, and maximum load. Results When data from dorsally and volarly applied plates were pooled, we did not find any statistically significant differences between them regarding stiffness, yield load, and maximum load. The K-wire group showed significantly lower yield load than 3 of the plate groups. There were no statistically significant differences in yield load between the 5 plate groups. The K-wire group showed lower rigidity than the plate groups. The K-wire group and 1 plate group failed at a statistically significant lower maximum load than the 4 other plate groups. Interpretation The volar plates had the same mechanical stability as the dorsally applied plates, and they are therefore a good alternative to dorsally applied plates. K-wire osteosynthesis was inferior to plate osteosyntheses regarding all mechanical properties.

A survivorship study of 838 total elbow replacements: a report from the Norwegian Arthroplasty Register 1994-2016

BACKGROUND The aim of this study was to present the long-term survivorship (20 years) of total elbow arthroplasty (TEA) for a relatively large population and to compare different prosthesis brands and patient subgroups. METHODS Between 1994 and 2017, a total of 838 primary TEAs were reported to the Norwegian Arthroplasty Register. Implant survival was calculated using the Kaplan-Meier method. Risk differences were examined using Cox regression analyses and exact Cox regression for rare events. We compared the survivorship of the 8 most frequently used implant brands, the different diagnoses leading to TEA, and the influence of the fixation technique. RESULTS The overall 5-, 10-, 15-, and 20-year survival rates for all elbow arthroplasties were 92%, 81%, 71%, and 61%, respectively. Risk factors for revision were a diagnosis of sequelae after trauma and cementless fixation of the ulna component. There were some differences between the implant brands. The Norway prostheses had higher survival compared with the Kudo after 15 years of follow-up (78% and 66%, respectively; P < .001). Among the implants with shorter follow-up, the IBP and NES had inferior survivorship compared with the Norway. The frequently used Discovery had promising survivorship up to 5 years. The most frequent reason for revision surgery was aseptic loosening, followed by defective polyethylene, infection, and dislocation. The revision causes were to some degree implant specific. CONCLUSION Fairly good results in terms of prosthesis survival were obtained with TEA, although results were poorer than for knee and hip arthroplasties.