Randomized, double-blind, clinically controlled trial of intranasal calcitonin treatment in patients with hip fracture.

The objective of this study was to evaluate the short-term outcome of intranasal calcitonin treatment of elderly hip fracture patients on pain, bone loss, functional recovery, and length of hospital stay. In addition, we wanted to compare the effect of calcitonin with placebo on fusion of hip fractures treated with internal fixation using a screw or a nail. In a randomized, double-blind, clinically controlled trial, 260 independently living patients (aged 65 years or older) with acute hip fracture were randomly assigned to intranasal calcitonin 200 IU daily for 3 months or matching placebo nasal spray. Analyses were completed on an intention-to-treat basis. Three months after the operation, the median intensity of pain in visual analog scale was 0 mm (IQR 0.20) in the calcitonin group and 4 mm (IQR 0.33) in the placebo group (P = 0.15). The mean change in calcaneal bone mineral density from baseline to 3 months was not statistically significant between the groups -0.004 (95% CI -0.008 to -0.001) in the calcitonin group and -0.007 (95% CI -0.012 to -0.003) in the placebo group (P = 0.28). There were no significant differences in mortality, side effects, length of hospital stay, and functional recovery. Among patients with internal fixation using a screw or a nail (n = 99), fusion of the fracture was observed in an X-ray 3 months after the operation in 84% in the calcitonin group and in 63% in the placebo group (P = 0.029, difference 20% [95% CI 2 to 39]). We conclude that intranasal calcitonin might be useful for hip fracture patients but the clinical significance of this finding needs to be confirmed by studies with more participants, a longer treatment period, a longer follow-up, and perhaps a higher dose of calcitonin.

Threefold increased risk of hip fractures with rheumatoid arthritis in Central Finland.

OBJECTIVES: To evaluate the impact of rheumatoid arthritis (RA) on the incidence of hip fractures. METHODS: All patients with acute hip fractures admitted to Jyväskylä Central Hospital in 1991-93 (n=517) were selected from the hospital discharge register. Medical records of these patients were studied retrospectively for RA fulfilling the American Rheumatism Association criteria. The prevalence of RA in patients with hip fractures was compared with the prevalence rates of RA obtained from the nearby city of Tampere. RESULTS: 29 (5.6%; 95% CI 3.8 to 8.0) of the patients with hip fracture in Jyväskylä Central Hospital had RA. The age and sex adjusted risk of hip fractures was increased by RA (risk ratio 3.26; 95% CI 2.26 to 4.70). CONCLUSIONS: Patients with RA are at increased risk of osteoporotic hip fractures.

Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia.

OBJECTIVE: To evaluate the effect of intensive geriatric rehabilitation on demented patients with hip fracture. DESIGN: Preplanned subanalysis of randomised intervention study. Settting: Jyväskylä Central Hospital, Finland. PARTICIPANTS: 243 independently living patients aged 65 years or older admitted to hospital with hip fracture. INTERVENTION: After surgery patients in the intervention group (n=120) were referred to the geriatric ward whereas those in the control group were discharged to local hospitals. MAIN OUTCOME MEASURES: Length of hospital stay, mortality, and place of residence three months and one year after surgery for hip fracture. RESULTS: The median length of hospital stay of hip fracture patients with moderate dementia (mini mental state examination score 12-17) was 47 days in the intervention group (n=24) and 147 days in the control group (n=12, P=0.04). The corresponding figures for patients with mild dementia (score 18-23) were 29 days in the intervention group (n=35) and 46.5 days in the control group (n=42, P=0.002). Three months after the operation, in the intervention group 91% (32) of the patients with mild dementia and 63% (15) of the patients with moderate dementia were living independently. In the control group, the corresponding figures were 67% (28) and 17% (2). There were no significant differences in mortality or in the lengths of hospital stay of severely demented patients and patients with normal mini mental state examination scores. CONCLUSIONS: Hip fracture patients with mild or moderate dementia can often return to the community if they are provided with active geriatric rehabilitation.

Population based epidemiologic and morphologic study of femoral shaft fractures.

The epidemiologic and morphologic features of all femoral shaft fractures in skeletally mature patients treated during a 10-year period in a semi-urban county were analyzed. Among an average adult population of 202,592 residents, 192 people sustained 201 traumatic femoral shaft fractures during the study period. The incidence was 9.9 fractures per 100,000 person-years. The highest age and gender specific incidences were seen in males from 15 to 24 years of age and in females 75 years of age or older. Seventy-five percent (151) of the fractures were the result of a high-energy trauma, 131 of which occurred in road traffic accidents. Unexpectedly, there were 50 low-energy fractures. Fractures of the middle 1/3 of the diaphysis were 79%. The majority, 155 (77%), of all fractures were transverse, oblique, or oblique transverse. Regarding the degree of comminution, the Winquist and Hansen Grade 0 (noncomminuted) fracture was the most common. Forty-eight percent of fractures were AO Type A, 39% were Type B, and 13% were Type C fractures. Of the 25 open fractures, 14 were Gustilo Type II. All six Type III open injuries were Type IIIA. Based on the data from the current study, most of the femoral fractures in this community might be treated adequately with conventional intramedullary nails, rather than using interlocking nails, provided the stability of fixation and fracture alignment can be maintained. Preventive measures against femoral shaft fractures should focus on protection of automobile drivers, especially young men, and on effective treatment of osteoporosis in elderly women.

Significant changes in the surgical methods and length of hospital stay of hip fracture patients occurring over 10 years in Central Finland.

BACKGROUND AND AIMS: The objective of this study is to determine the changes occurring in the treatment chain and mortality of hip fracture patients in Central Finland over a ten-year period. In order to cope with an aging population and increasing cutbacks in the health care system, health-center hospitals run by general practitioners have taken a more active role in the rehabilitation of elderly patients. MATERIAL AND METHODS: Patients with acute hip fracture admitted to Jyväskylä Central Hospital in 1982-1983 (n = 317) and in 1992-1993 (n = 351) were collected from the hospital discharge register and the medical records of these patients were studied retrospectively. RESULTS: The median length of central hospital stay diminished from 18 days to 5 days and the percentage of hip fracture patients discharged to cope on their own diminished from 22 % to only 7 %. The percentage of trochanteric fractures treated by osteosynthesis increased from 83 % to 96 % and the percentage of cervical fractures treated by hemiprosthesis increased from 35 % to 76 %. First-year mortality has remained almost unchanged. CONCLUSIONS: There has been a dramatic change in surgical methods, in the length of hospital stay on the traumatology ward, and in discharge patterns and no change in mortality during the last 10 years in Central Finland.

Asymmetry of paraspinal EMG-time characteristics in idiopathic scoliosis.

The purpose of this study was to investigate the activation pattern of the paraspinal muscles in scoliotic and normal subjects. Force-time and electromyography (EMG)-time curves of paraspinal muscles were recorded during maximal isometric trunk extensions in 15 girls with adolescent idiopathic scoliosis (AIS) and in 14 healthy girls with structurally normal spines. The isometric force-time curves as well as the maximal integrated electromyography (IEMG) activities that were recorded from both sides of the thoracic and lumbar spine did not show any significant differences between the two subject groups. However, in the subjects with AIS, the IEMG activities recorded at the onset and during the early (submaximal) phases of muscle contraction were significantly higher in the left lumbar muscles compared with the right side. The observed intensity-specific EMG asymmetry in the present scoliotic subjects may be attributed to the imbalanced neural input associated with AIS that may also have pathogenetic importance in the etiology of idiopathic scoliosis.

The changing picture of hip fractures: dramatic change in age distribution and no change in age-adjusted incidence within 10 years in Central Finland.

The objective of this study was to find out if the age-standardized incidence of hip fractures has changed in 10 years in Central Finland. Patients with acute hip fracture admitted to Jyväskylä Central Hospital in 1982-1983 (n = 317) and in 1992-1993 (n = 351) were selected from the hospital discharge register and from contemporaneous records of the Department of Anesthesiology and the ward of traumatology. Earlier studies in Finland have indicated that there has been an increase in incidence rates. The results of this study show no change in the age-standardized incidence of hip fractures of men and women during the last 10 years. However, because of the change in the age distribution of the population, the number of hip fractures has increased by 11%. The mean age of the hip fracture patients increased from 75.4 years in 1982-1983 to 78.4 years in 1992-1993. In 1982-1983, 18.0% of the patients were > or =85 years. The corresponding figure in 1992-1993 was 30.2%. Therefore, we summarize that there has been a dramatic change in age distribution and no change in age-adjusted incidence within the last 10 years in central Finland.

Calcaneal bone mineral density predicts fracture occurrence: a five-year follow-up study in elderly people.

A 5-year follow-up study investigated calcaneal bone mineral density (BMD) and changes in BMD in relation to fracture occurrence. The subjects comprised two cohorts born in 1914 and 1910 living in the city of Jyväskylä in central Finland. One hundred and three men (82%) and 188 women (73%), aged 75, and 57 men (74%) and 136 women (65%), aged 80, of the eligible population participated in the baseline bone measurements. The follow-up bone measurements were obtained for 59 men (68%) and 119 women (66%), aged 80 years, and for 21 men (53%) and 61 women (48%), aged 85 years. During the follow-up period, 8 men and 36 women from the younger and 11 men and 24 women from the older cohort sustained at least one fracture. When the baseline levels of BMD were related to fracture occurrence, the results clearly showed that with increased BMD values the probability of fracture decreased. Where men and women had similar BMD values, they also had a similar fracture probability. Except for one woman in the older cohort, none of those who had initial BMD values more than 1 standard deviation above the mean for their age developed a fracture during the follow-up period. The mean annual decrease in BMD was greater in the women (2.5-2.7%) than in the men (0.8-1.0%). The BMD change tended to associate with fracture occurrence only in the 75-year-old women (p = 0.075). The results suggest that calcaneus BMD can be used as a predictor of fracture occurrence in 75- to 80-year-old men and women. However, associating fractures with the change in BMD was difficult due to the limited number of survivors and initial differences in BMD values.

Specific features associated with femoral shaft fractures caused by low-energy trauma.

OBJECTIVE: To scrutinize the fracture patterns of femoral shaft fractures caused by low-energy injury mechanism and to delineate the problems associated with the treatment of these fractures. MATERIALS AND METHODS: Of a total of 192 consecutive skeletally mature patients with 201 acute fresh femoral shaft fractures admitted during a 10-year period (1985-1994), 50 patients had a fracture caused by low-energy trauma. The fractures were classified in terms of their configuration, site, degree of comminution, and soft-tissue injury. The previous fractures, chronic illnesses, and continuous medications of the patients as well as the injury mechanisms and concomitant injuries were registered. All general and local complications and their consequences were recorded. Forty patients could be followed until the bony union of the fracture was achieved, the mean follow-up time being 14 months. RESULTS: The incidence of these injuries was 2.5 per 100,000 person-years. There were 32 women and 18 men. The mean age of the patients was 65 years (range, 17-92 years). Thirteen patients were younger than 60 years of age. Thirty-two (64%) had at least one local or general factor weakening the mechanical strength of the bone that predisposed them to a fracture. Thirty-two patients sustained a fracture of the left femur (p < 0.05). All fractures were closed. None of the patients had significant concomitant injuries. In 33 cases, the site of the fracture was in the middle third of the femur. The fracture configuration was spiral in 29, transverse in 10, oblique-transverse in 7, and oblique in 4 cases. Postoperative complications, including delayed union, nonunion, and malunion, occurred with 29 patients. Eighteen reoperations among 12 patients were performed because of these complications. CONCLUSIONS: Femoral shaft fractures caused by low-energy violence occur mainly in patients suffering from a chronic disease or a condition causing osteopenia of the femur. The most common fracture pattern was a spiral one in the middle third of the femoral shaft. Despite the low-energy violence, the treatment of these fractures is not devoid of complications. The treatment of these seemingly simple fractures requires careful planning and meticulous operative technique.

Low molecular weight heparin (enoxaparin) compared with unfractionated heparin in prophylaxis of deep venous thrombosis and pulmonary embolism in patients undergoing hip replacement.

Prophylactic efficacy and safety of a low molecular weight heparin (LMWH) and those of conventional unfractionated heparin (UH) were investigated in a randomized study. Totally, 167 consecutive patients undergoing total hip replacement were allocated to two groups. Patients in the LMWH-group (n = 83) received a fixed dose of enoxaparin 40 mg once daily, starting 12 hours preoperatively and continuing for 10 days. Patients in the UH-group (n = 84) received UH 5000 IU twice a day subcutaneously (sc), starting two hours before operation and continuing for 10 days. Deep venous thrombosis (DVT) was diagnosed by bilateral ultrasonography and confirmed by venography. Proximal DVTs were observed in four patients of UH-group (4.8%) and in one of LMWH-group (1.2%, P > 0.05). There was only one pulmonary embolism (PE) in a patient belonging to UH-group (1.2%). Low rates of thromboembolic events could be explained, in addition to heparin prophylaxis, also by early mobilization and regional anaesthesia. Local tolerance (size of haematoma), blood loss and transfusion requirements during the operation and the postoperative period did not show differences between the two study groups. The results of our study indicate that enoxaparin once daily is an effective and safe form of DVT prophylaxis in patients undergoing elective hip replacement.

Four-year survival after hip fractures--an analysis in two Finnish health care regions.

We studied the survival of 390 patients with fresh hip fractures sustained in 1989 by a population of about 441 thousand in two health care regions in Finland during four years. The most significant explanatory factors of mortality were place of injury, place after primary treatment and age. The excess mortality of men compared with the reference population at one year was 21% and in women 16%. After this, the excess mortality rates increased slowly in both sexes and were 37% for men and 24% for women at four years. In those who had sustained the fracture in a traffic accident the mortality at four years was slightly lower than that in the reference population, and in those who had sustained the fracture in other accident outdoors there was a 10% excess mortality. Patients who had sustained the injury at home had at four years a 25% and those who had sustained the injury in institutions a 46% excess mortality. The excess mortality at four years was lowest in those who were discharged home (14%) and highest in those who were discharged to other institutions (27%).

Survival of the Lubinus hip prosthesis. An eight- to 12-year follow-up evaluation of 444 cases.

The Kaplan-Meier survival method was used to analyze 444 Lubinus arthroplasties in 398 patients who were observed between eight and 12 years. The indication for arthroplasty was osteoarthrosis in 316 hips, rheumatoid arthritis in 84 hips, and various other conditions for the other 44 hips. Survival was determined for the entire prosthesis, as well as separately for the femoral stem, the acetabulum cup, and their four subgroups. Four patient-related variables (diagnosis, gender, age, and weight) were analyzed. The overall survival of the Lubinus implants was 97.1% at five years and 87.1% at ten years. No significant difference in survival was found between the acetabular and femoral components. Survival was not significantly better with a new anatomic (SP1) stem than with the old curved one (IP). Of the four patient-related variables studied, only diagnosis and age had a significant effect on prosthesis survival. There was no difference in survival between osteoarthrosis and rheumatoid arthrosis hips, but survival was clearly poorer at ten years in the miscellaneous diagnosis group. The authors obtained a significantly lower survival percentage for patients younger than 65 years of age than for those 65 years and older. There were no deep postoperative infections in this series. The revision rate was 11.5%. The wear seen at the lower front edge of cups that were removed is discussed.

Adductor magnus tenodesis for patellar dislocation. Technique and preliminary results.

Fourteen patients with acute or chronic patellar instability had treatment with a new reconstructive procedure. It consists of isokinetic augmentation of the medial patellofemoral ligament (PFL) by making a tenodesis of the distal adductor magnus tendon to the medial border of patella. The patients were reviewed at a mean of 6.9 +/- 0.5 years after operation. In 12 patients, the subjective result was good. One patient had redislocation.

Are smokers a risk group for delayed healing of tibial shaft fractures?

A total of 135 patients with a fresh tibial shaft fracture and with no other significant injuries underwent primary conservative treatment. Data on their smoking habits were obtained from hospital records and by questionnaire. Although the smokers had better prospects for healing of the fracture at the outset than non-smokers (lower mean age and less fractures caused by high-energy injuries), the smokers were found to have a significantly longer mean time to clinical union and a higher incidence of delayed union. According to a crude calculation, smokers had a 4.1-fold risk of tibial shaft fracture caused by low-energy injury, compared with non-smokers. An accelerated failure time model showed that the more comminuted or open the fracture, the higher the number of cigarettes smoked and the older the patient, the longer was the time to clinical union of the tibial shaft fracture. Female sex appeared to be a further risk factor for delayed healing. A logit model indicated that comminution of the fracture, smoking and female sex were associated with delayed union and non-union. If a patient has a markedly raised probability of delayed union of tibial shaft fracture because of many risk factors as reported in the previous literature or in this study, operative treatment should be considered as the primary alternative instead of conservative treatment. Stopping smoking during healing of tibial shaft fracture could also promote the union of the fracture.

Hip fractures in two health care regions in Finland in 1989: an analysis of treatment.

We studied prospectively the demographic data, fracture types and modes of treatment in 390 patients with acute traumatic hip fractures in two health care regions in Finland, the Middle Finland region and the Kymenlaakso region in 1989. In Middle Finland population (251,203 inhabitants) 199 patients with a hip fracture were admitted to two acute care hospitals, while 191 patients were admitted in Kymenlaakso (population 189,726) to four acute hospitals. There were no significant differences in the sex- and age-specific incidences between the two regions. In Middle Finland, 70% of the fractures were of the femoral neck, 28% were trochanteric and 2% subtrochanteric. The corresponding figures in Kymenlaakso were 57%, 38% and 5% (P < 0.05). In Middle Finland, 73% of the femoral neck fractures were treated primarily with a hemiendoprosthesis, 2% with primary total hip replacement and 25% by osteosynthesis. The corresponding figures in Kymenlaakso were 81%, 7% and 12% (P < 0.001). The mean duration of hospital stay was 14 days in Middle Finland and 21 days in Kymenlaakso (P < 0.01).

Hip fractures in urban population in Finland.

We studied prospectively the occurrence of hip fractures among the over 49-year-old urban populations (n = 88,206) in the cities Tampere, Jyväskylä and Kotka in 1989 and compared the results with a parallel Scandinavian multicentre study. During 1989, there were 266 inhabitants who were treated for a hip fracture, 213 of them were women. Women had in 132 cases a femoral neck fracture and in 81 cases a trochanteric fracture, and the corresponding numbers for men were 22 and 31. Among women, the total hip fracture incidence in Jyväskylä (n = 22) was the lowest when compared with the ones in Tampere (n = 47) and Kotka (n = 36). These incidences were on average lower than in the other Scandinavian cities studied in parallel. The all over ratio of femoral neck/trochanteric fractures was 1.1 in Tampere, 3.0 in Jyväskylä and 2.2 in Kotka and in Tampere, women had 9.3 times more femoral neck fractures than men. Our study showed that in Finland in three major cities the hip fracture incidence was lower than what has been similarly registered in corresponding urban populations in other Scandinavian countries. We also point out that the relative part of trochanteric fractures appears to be increasing.

Platelet activation during acute phase after multiple trauma.

The acute phase after multiple trauma is associated with both thrombotic phenomena and a bleeding diathesis. To evaluate the activation of platelets, beta-thromboglobulin (BTG) in plasma and serum and thromboxane B2 (TxB2) in serum were measured in 14 patients with multiple trauma. BTG in plasma was significantly increased on days 1, 2 and 10 to 14 after the trauma. The highest median value 90 micrograms/l was measured on day 1. BTG in serum was significantly reduced 1 to 7 days after the trauma (median levels 4450-9100 micrograms/l). TxB2 was significantly reduced (median levels 18-97 ng/l) on days 1 to 14. The increased plasma levels of BTG is due to the posttraumatic activation of platelets in vivo. The reduced levels of serum BTG and TxB2 reflect the deficient functional capacity of circulating platelets to respond to extreme stress. Therefore, platelet count alone may correlate poorly with the haemostatic potential and may underestimate the need of platelet transfusions.

Blunt injury patients benefiting from intensive care.

The files of 2,002 trauma patients admitted to our intensive care unit between 1966 and 1984 were analyzed. 74% of the patients were admitted because of the trauma after primary care and 26% later. The main reasons for later admissions were respiratory distress in 11% and postoperative follow-up in 8% of the cases. The series consists of blunt injury patients with a mean age of 39 years for those who survived and 52 years for those who died. 65% of the patients were injured in road traffic accidents. Injuries to the lower extremity were the most frequent (60%) and injuries to the cervical spine the least frequent (11%). The injury Sum (= sum of injuries) ranged from 1 to 18 with an average of 5.6 in the whole series. Two thirds of the patients were multiply injured. A statistical analysis showed that the most important determinants between the dead and those who survived were resuscitation, need for respirator treatment, age of the patient, amount of primary blood transfusions, brain and renal complications. The ICU mortality was 9.0% and the total hospital mortality was 11.9%.

A prospective study of the treatment of severe tears of the lateral ligament of the ankle.

A prospective randomized clinical study was undertaken to compare bandaging, plaster cast immobilisation and operative treatment for recent tears of the lateral ligament of the ankle. The follow-up period was two years. Subjectively, only the fear of giving-way showed a clear difference in favour of operative repair. Objective evaluation, including stress radiographs, demonstrated no statistical differences between the three methods of treatment. Although bandaging appeared somewhat less satisfactory with respect to the resulting stability of the ankle, the differences were not statistically significant. The lateral ligament in patients over 40 years of age showed a statistically significant tendency to heal less well than that of younger patients. Severe ankle sprains in patients under 40 years of age should preferably be treated by operation, especially in younger patients and if the person is physically active. Lateral ligament tears in patients over 40 years of age should be treated conservatively and a secondary reconstruction carried out later, if necessary.