Cross cultural adaptation and psychometric properties of the Finnish version of Western Ontario shoulder instability index (WOSI).

BACKGROUND: Western Ontario shoulder instability index (WOSI) is a widely used disease-specific self-assessment measurement tool for patients with shoulder instability. The main aim of this study was to translate and cross culturally adapt the WOSI into Finnish language and to test its measurement properties. METHODS: WOSI was translated in Finnish and adapted into an electronic user interface. 62 male patients with traumatic anteroinferior shoulder instability, programmed for stabilizing shoulder surgery, answered the questionnaire twice preoperatively (2 and 0 weeks), and twice postoperatively (3 and 12 months). Additional scoring tools, such as satisfaction to treatment outcome, subjective shoulder value (SSV), Oxford shoulder instability index (OSIS) and Constant score (CS), were used as comparators. The reliability, validity and responsiveness of WOSI were investigated through statistical analysis. RESULTS: Preoperative test-retest results were available for 49 patients, and 54 patients were available at final follow up. The mean WOSI was 57.8 (SD 20.3), 70.4 (SD 18.9), and 85.9 (SD 15.5), at baseline, 3, and 12 months, respectively. There was a statistically significant mean improvement of 28.8 (SD 24.5) in WOSI between baseline and 12 months (p < 0.0001). The intraclass correlation coefficient for the preoperative WOSI was excellent 0.91. At 12 months WOSI had an excellent Pearson's correlation coefficient both with SSV (0.69), OSIS (-0.81), and poor with CS (0.25) scores, confirming our a priori hypothesis. There were no detected floor nor ceiling effects for WOSI pre- or postoperatively. The calculated minimal detectable change was 9.2 and the estimated minimal clinically important difference 13.4 to 18.1. CONCLUSION: Finnish version of WOSI is a reliable and valid tool for assessing health state and improvement after operative treatment of shoulder instability in young male patients.

Epidemiology of Flexor Tendon Injuries of the Hand in a Northern Finnish Population.

BACKGROUND: Flexor tendon injuries cause significant morbidity in working-age population. The epidemiology of these injuries in adult population is not well known. The aim of this study was to describe the epidemiology of flexor tendon injuries in a Northern Finnish population. MATERIAL AND METHODS: Data on flexor tendon injuries, from 2004 to 2010, were retrieved from patient records from four hospitals, which offer surgical repair of the flexor tendon injuries in a well-defined area in Northern Finland. The incidence of flexor tendon injury as well as the gender-specific incidence rates was calculated. Mechanism of injury, concomitant nerve injuries, and re-operations were also recorded. RESULTS: The incidence rate of flexor tendon injury was 7.0/100,000 person-years. The incidence was higher in men and inversely related to age. The most common finger to be affected was the fifth digit. In 37% of injuries also digital nerve was affected. The most common finger to have simultaneous digital nerve injury was the thumb. CONCLUSION: Flexor tendon laceration is a relatively rare injury. It predominantly affects working-aged young males and frequently includes a nerve injury, which requires microsurgical skills from the surgeon performing the repair. This study describes epidemiology of flexor tendon injuries and therefore helps planning the surgical and rehabilitation services needed to address this entity.

Diagnostic accuracy of the gravity stress test and clinical signs in cases of isolated supination-external rotation-type lateral malleolar fractures.

We prospectively assessed the diagnostic accuracy of the gravity stress test and clinical findings to evaluate the stability of the ankle mortise in patients with supination-external rotation-type fractures of the lateral malleolus without widening of the medial clear space. The cohort included 79 patients with a mean age of 44 years (16 to 82). Two surgeons assessed medial tenderness, swelling and ecchymosis and performed the external rotation (ER) stress test (a reference standard). A diagnostic radiographer performed the gravity stress test. For the gravity stress test, the positive likelihood ratio (LR) was 5.80 with a 95% confidence interval (CI) of 2.75 to 12.27, and the negative LR was 0.15 (95% CI 0.07 to 0.35), suggesting a moderate change from the pre-test probability. Medial tenderness, both alone and in combination with swelling and/or ecchymosis, indicated a small change (positive LR, 2.74 to 3.25; negative LR, 0.38 to 0.47), whereas swelling and ecchymosis indicated only minimal changes (positive LR, 1.41 to 1.65; negative LR, 0.38 to 0.47). In conclusion, when gravity stress test results are in agreement with clinical findings, the result is likely to predict stability of the ankle mortise with an accuracy equivalent to ER stress test results. When clinical examination suggests a medial-side injury, however, the gravity stress test may give a false negative result.

Open Latarjet procedure for failed arthroscopic Bankart repair.

INTRODUCTION: This retrospective study assessed the functional results of open Latarjet operation for recurrence of instability after arthroscopic Bankart repair in a consecutive series of patients. MATERIALS AND METHODS: Fifty two patients (mean age 28.4 [range 17-62] years, 45 men) were operated on using open Latarjet operation after one (n=46) or two (n=6) failed arthroscopic Bankart repairs. The indication for revision surgery was recurrent dislocation or subluxation. Fifty patients had a Hill-Sachs lesion and 32 patients had glenoid bone lesions on plain radiographs. No attempt was made to grade the severity of bony pathology. Functional outcome and stability of 49 shoulders were assessed after an average follow-up of 38 (range 24-85) months using Western Ontario Shoulder Instability (WOSI) score, Oxford shoulder instability score, and subjective shoulder value (SSV). RESULTS: Forty-two patients had a stable shoulder at follow-up. Seven of 49 (14%) had symptoms of instability; one patient had recurrent dislocation, and six patients had subluxations. Mean WOSI, Oxford, and SSV scores were 83.9, 19.9, and 84.9, respectively. All scores were significantly better in patients who had a stable shoulder compared with those who had an unstable shoulder (WOSI 86.8 vs. 64.3; Oxford 18.2 vs. 30.8; and SSV 88.3 vs. 61.7; P<0.01). One patient needed a reoperation. There were no intraoperative or postoperative complications. CONCLUSIONS: Open Latarjet operation is a good option for failed arthroscopic Bankart repair. The instability recurrence rate is acceptable and the reoperation rate was low. LEVEL OF EVIDENCE: Level IV, retrospective case series.

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.

Short- to mid-term results of metallic press-fit radial head arthroplasty in unstable injuries of the elbow.

We assessed the short- to mid-term survival of metallic press-fit radial head prostheses in patients with radial head fractures and acute traumatic instability of the elbow. The medical records of 42 patients (16 males, 26 females) with a mean age of 56 years (23 to 85) with acute unstable elbow injuries, including a fracture of the radial head requiring metallic replacement of the radial head, were reviewed retrospectively. Survival of the prosthesis was assessed from the radiographs of 37 patients after a mean follow-up of 50 months (12 to 107). The functional results of 31 patients were assessed using range-of-movement, Mayo elbow performance score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score and the RAND 36-item health survey. At the most recent follow-up 25 prostheses were still well fixed, nine had been removed because of loosening, and three remained implanted but were loose. The mean time from implantation to loosening was 11 months (2 to 24). Radiolucent lines that developed around the prosthesis before removal were mild in three patients, moderate in one and severe in five. Range of movement parameters and mass grip strength were significantly lower in the affected elbow than in the unaffected side. The mean MEPS score was 86 (40 to 100) and the mean DASH score was 23 (0 to 81). According to RAND-36 scores, patients had more pain and lower physical function scores than normal population values. Loosening of press-fit radial head prostheses is common, occurs early, often leads to severe osteolysis of the proximal radius, and commonly requires removal of the prosthesis.

Epidemiology and seasonal variation of distal radius fractures in Oulu, Finland.

UNLABELLED: The purpose of this study was to assess changes in epidemiology and reasons for wintertime excess of distal radius fractures in Oulu, Finland. Our results showed that age-specific incidence of distal radius fractures in elderly women in Finland has increased compared with a previous study. Slippery pavement surfaces assessed by a new meteorological model partly explained wintertime excess of fractures, but factors beyond weather are contributing to seasonality. INTRODUCTION: In this report, we describe the epidemiology and seasonal variation of distal radius fractures in Oulu, Finland, with a focus on the effect of weather and slippery pavement conditions. METHODS: Records of patients aged ≥16 years living in Oulu with a distal radius fracture during the year 2008 were reviewed. Demographic data and details of the injury were assessed from medical records, and fractures were classified according to AO classification. Population data for Oulu during the year 2008 were used to calculate crude incidence as well as sex- and age-specific incidence rates. The number of wintertime fractures was compared with those related to pavement surface slipperiness using a unique weather and pavement condition model of the Finnish Meteorological Institute. RESULTS: The crude incidence was 258/100,000 person-years. Sex- and age-specific incidence rates rose to 1,107/100,000 person-years for females and 466/100,000 person-years for males aged ≥80 years. Poisson regression analysis showed that the number of fractures was 2.5 (95% confidence interval (CI), 1.6 to 4.0; P < 0.001) times greater on slippery winter days compared with non-winter days whereas on normal winter days fractures were 1.4 (95% CI, 1.1 to 1.9; P = 0.01) times greater. Both low- and high-energy injuries resulted in similar fracture patterns by AO classification. CONCLUSIONS: Our results suggest that the epidemiology of distal radius fractures in elderly women in Finland has changed compared with a previous study. Weather analysis showed that the slipperiness of the pavement could partly explain the wintertime excess of distal radius fractures.

Articular bone loss treated with a staged method using bone cement or beads as a spacer and subsequent autografting: a report of two cases.

Fractures with bone loss are rare. Cancellous autografting is commonly used to treat metaphyseal and diaphyseal traumatic bone loss, but little is known about the applicability of this method to the treatment of intra-articular bone loss. We report two cases of articular bone loss that were treated with a staged method of using antibiotic-impregnated bone cement in one case and beads in another as spacer in the primary phase and cancellous autografting in second-stage surgery.

RhBMP-7 accelerates the healing in distal tibial fractures treated by external fixation.

External fixation of distal tibial fractures is often associated with delayed union. We have investigated whether union can be enhanced by using recombinant bone morphogenetic protein-7 (rhBMP-7). Osteoinduction with rhBMP-7 and bovine collagen was used in 20 patients with distal tibial fractures which had been treated by external fixation (BMP group). Healing of the fracture was compared with that of 20 matched patients in whom treatment was similar except that rhBMP-7 was not used. Significantly more fractures had healed by 16 (p=0.039) and 20 weeks (p=0.022) in the BMP group compared with the matched group. The mean time to union (p=0.002), the duration of absence from work (p=0.018) and the time for which external fixation was required (p=0.037) were significantly shorter in the BMP group than in the matched group. Secondary intervention due to delayed healing was required in two patients in the BMP group and seven in the matched group. RhBMP-7 can enhance the union of distal tibial fractures treated by external fixation.

Interscalene brachial plexus block is superior to subacromial bursa block after arthroscopic shoulder surgery.

BACKGROUND: Arthroscopic shoulder surgery is often associated with severe postoperative pain. The results concerning subacromial bursa blockade (SUB) as a method of pain relief have been contradictory. We hypothesized that a SUB and interscalene brachial plexus block (ISB) would similarly reduce early postoperative pain and the need for oxycodone as compared to placebo (PLA). METHODS: Forty-five patients scheduled for arthroscopic shoulder surgery were enrolled in this randomised, prospective study. The ISB and SUB blockades were performed with 15 ml of ropivacaine (5 mg/ml). In the PLA group, 15 ml of 0.9% saline was injected into the subacromial bursa. All patients received general anaesthesia. RESULTS: The mean intravenously patient-controlled delivered oxycodone consumption during the first 6 h was significantly lower in the ISB group (6 mg) than in the SUB group (24.1 mg; P=0.001) or in the PLA group (27 mg; P<0.001). No significant differences were detected between the SUB and PLA groups (P=0.791). The postoperative pain scores during the first 4 h at rest and during the first 6 h on movement were significantly lower in the ISB group than in the SUB and PLA groups. CONCLUSION: After arthroscopic shoulder surgery SUB has a minor effect only on postoperative analgesia, whereas an ISB with low-dose ropivacaine effectively relieves early postoperative pain and reduces the need for opioids.

Nonunion after intramedullary nailing of humeral shaft fractures.

OBJECTIVE: To assess results of exchange nailing in nonunion after intramedullary (IM) nailing of humeral shaft fractures. METHODS: This was a retrospective study; 24 patients with nonunion after IM nailing of humeral shaft fractures were reviewed. In 13 cases, nonunion was treated using exchange nailing, and 11 patients were treated nonoperatively. Union was assessed from radiographs. Shoulder joint symptoms and function were assessed after a mean 4.7 years' follow-up using Constant-Murley scoring and self-administered questionnaires devised by L'Insalata et al. RESULTS: Single or repeated exchange nailing resulted in union in 6 of 13 patients. Shoulder joint function was satisfactory (mean Constant-Murley score of 72) for those patients whose fracture eventually united and poor (mean Constant-Murley score of 39) for those left with nonunion. CONCLUSION: Exchange nailing results in a poor union rate in nonunion after IM nailing of humeral shaft fractures. Permanent nonunion of the humeral shaft leaves the patient with severe disability.

Penetration of Ullevaal hip screw into the pelvis.

The fracture of the femoral neck is usually treated operatively with screw osteosynthesis or prosthesis. There have been reported a rare complication both with screws and lag screws used in hip fractures, both can penetrate into the pelvis postoperatively. We present two cases with this similar rare complication when using Ullevaal screws. Both patients were reoperated on with a total hip arthroplasty (THA). We think that the exact anatomical reposition and good operation technique should make this complication even more rare. The canal should always be drilled only to the line of the fracture, so that there is no canal for the screw to squeeze further. To prevent penetration some kind of cap fixed the lateral end of the screw could also be worth while.

Early recovery of isometric shoulder muscle strength after open acromioplasty in stage II impingement syndrome.

The recovery of shoulder muscle strength after open acromioplasty was evaluated in 48 patients (27 male, 21 female, mean age 44.3 years) who had undergone open acromioplasty because of stage II impingement syndrome. The isometric strengths of flexion, abduction and external rotation were measured before the operation and at 3, 6 and 12 months postoperatively. The mean preoperative flexion strength of the involved shoulder was 72.6% of that of the uninvolved shoulder, and this increased to 77.1% by 3 months post operation, to 88.3% at 6 and to 88.3% at 12 months. Corresponding abduction strengths were 68.4%, 80.4%, 88.7% and 91.0% and the external rotation strengths were 75.1%, 77.4%, 95.1% and 93.5%, respectively. These recoveries were markedly improved when the cases with poor subjective results at 1 year were not considered. The low preoperative strengths were more pronounced in women than in men, but recovery was better in women. It is concluded that shoulder muscle strengths recover to near normal in 1 year after open acromioplasty.

Longitudinal split of peroneus brevis tendon. A report on two cases.

BACKGROUND AND AIMS: To describe the clinical findings and surgical treatment of peroneus brevis split. MATERIAL AND METHODS: Two cases of longitudinal split of the peroneus brevis tendon are reported. One of the patients was a healthy middle-aged woman, who had fallen out of a car in a traffic accident and sprained her right ankle. Lateral ankle sprain was diagnosed and treated with a compression bandage. Lateral ankle pain persisted, however, with some swelling in the peroneal tendon region. MRI revealed a longitudinal partial rupture of the peroneus brevis tendon, which was treated surgically 12 months after the trauma. The second case was a 53-year-old woman, who had been suffering from rheumatoid arthritis for 2 years. Chronic pain and swelling in the peroneal tendon region were treated with 6 local corticosteroid injections without significant relief. Preoperative ultrasonography showed effusion of the peroneal tenosynovium, but the operation revealed a longitudinal split in the peroneus brevis tendon. RESULTS: In the first case, a single central peroneus brevis split was repaired with side-to-side suturation. After four weeks with a below-knee cast the patient was allowed to walk freely. At follow-up 12 months postoperatively, she was satisfied, although she still had some exertion pain in her ankle. In the second case, the torn fragment of the peroneus brevis tendon was excised and the ankle was mobilized early. Healing was complicated by a wound fistula, which was treated with antibiotics. Subluxation of the peroneus longus tendon necessitated a reoperation, which revealed a rerupture and a defect of the peroneus brevis tendon. The subluxation was repaired and the ruptured tendon ends were revised, followed by four weeks of below-knee cast immobilization, after which the patient was allowed to walk freely. The outcome was good. CONCLUSION: Peroneus brevis split easily goes unrecognised or misdiagnosed. It must be considered in patients with a history of single or recurrent ankle sprain or a chronic inflammatory disease. Lateral ankle pain, diffuse or local swelling in the peroneal tendon region, and a stable or instable ankle with no peroneal weakness are the main symptoms and findings. MRI is the most exact method for diagnosing tendon split. Surgical treatment usually gives good results.

Corrective osteotomy for malunion of the distal radius.

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.

Role of metaphyseal cancellous bone defect size in secondary displacement in Colles' fracture.

The purpose of this study was to evaluate the role of the metaphyseal cancellous bone defect size in secondary dislocation of Colles' fracture. Thirty-five patients with a dislocated Colles' fracture were examined by computed tomography (CT) for metaphyseal bone defects. The size of the defect was assessed and related to the surface area of the cross-section of the distal radius at the site of the defect. The relative size of the defect correlated with the severity of dorsal angulation of the fracture but not with the shortening of the radius seen after cast immobilization. We concluded that secondary displacement of the distal radius is partly mediated through the metaphyseal cancellous bone defect, and to prevent malunion in dorsal angulation, operative treatment or possibly filling of the defect should be considered even as early as during primary reduction if a large defect is suspected.

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.

AO and Frykman's classifications of Colles' fracture. No prognostic value in 652 patients evaluated after 5 years.

We retrospectively assessed hand and forearm symptoms of 652 patients with a Colles' fracture, 5 years after the fracture, using a questionnaire. The contralateral forearm, which was free of major injuries or illnesses, was used as control. Forearm and hand symptoms were common and only one quarter of the fractured forearms were completely free of symptoms at the time of review, whereas four fifths of the control forearms had no symptoms. Nearly half of the patients complained of impairment in various activities and 8% had had to give up leisure activities or make special arrangements at work. Demographic, and most of the fracture-related factors, were not associated with the symptoms. Neither AO nor Frykman's radiographic classifications of the primary fracture were of any use for predicting the clinical outcome.

Pathological fractures of the humeral shaft.

BACKGROUND AND AIMS: To evaluate the results, complications and survival after intramedullary (IM) nailing of pathological humeral shaft fractures associated with metastatic disease. MATERIAL AND METHODS: Sixteen patients (mean age 64 years) with 18 pathological fractures of the humeral shaft were treated by IM nailing in Oulu University Hospital from 1987 to 1997. Retrospective evaluation of charts and radiographs was carried out. Breast carcinoma and multiple myeloma were the most common diagnoses. The mean interval from diagnosis of malignancy to fracture was 47 (1-168) months. RESULTS: Mean duration of the operation was 62 (25-95) minutes and mean intraoperative blood loss was 200 (50-600) ml. Complications were rare. Survival after the fracture averaged 160 (39-511) days. Two patients (3 fractures) were alive at the time of the evaluation, with satisfactory or good pain relief. CONCLUSIONS: Pathological fracture of the humeral shaft occurs late in the course of malignant disease. IM nailing is a safe, rapid and effective procedure for treating pathological fractures of the humeral shaft.