Etiology of facial fractures in elderly Finns during 2006-2007.

OBJECTIVE: The purpose of the present study was to clarify the trauma mechanisms and resulting facial fractures in geriatric patients and to compare them with those of younger adults. STUDY DESIGN: A cohort of 117 geriatric patients was compared with 136 patients aged 20 to 50 years. The statistical significance of differences between the age groups was evaluated with χ(2) tests. RESULTS: Falls on the ground were significantly more frequent among geriatric patients (P < .001), whereas assault was more frequent in controls (P < .001). Accident rates in geriatric patients were significantly higher during the winter months (P = .04). Fractures of the midface in general (P = .001) and of the nasal bone (P = .004) and orbit (P = .015) in particular were more frequent in geriatric patients. CONCLUSIONS: Age-related factors and preexisting medical problems predispose the elderly to falls and subsequent fractures. Footwear traction devices are recommended during the cold season. Orbital fractures should be strongly suspected in the elderly.

WITHDRAWN: Use of platelet rich plasma (PRP) in the reconstruction of mandibular bony defects: Clinical and radiographic follow-up.

PURPOSE OF THE STUDY: The purpose of the study was to evaluate the effect of adding platelet rich plasma (PRP) to a particulate autogenous bone graft in the healing of bony defects following ablative surgery to resect malignancies of the mandible. MATERIAL AND METHODS: Ten patients, who underwent curative surgical therapy for a malignant tumour and who needed reconstruction of the body of the mandible were selected for this study. The patients were randomly divided into two groups of five patients. In the first group, the defect was reconstructed using an autogenous free bone graft taken from the anterior iliac crest. The five patients in the second group underwent the same treatment, except that the bone graft was mixed with platelet rich plasma (PRP). Panoramic radiographs were taken immediately, at 1 month, 3 months and at 9 months intervals, after reconstruction. Radiographic evaluation took place in a standardized way by two independent examiners. RESULTS: The clinical outcome of the surgical reconstruction was satisfactory. The initial bone healing in all patients was uneventful. The postoperative successive radiographs showed adequate consolidation of the bone in all cases. Bone healing, as manifested by the obliteration of the bone gaps at the osteotomy sites, was particularly present in the PRP group at 3 months period. This was found to be statistically significant (Chi-square test, P<0.05). CONCLUSION: The use of PRP appeared to enhance bone healing considerably. PRP and autogenous free bone grafts might have a potential for routine clinical use to reconstruct bony defects.

Development of a three-dimensional finite element model of a human mandible containing endosseous dental implants. II. Variables affecting the predictive behavior of a finite element model of a human mandible.

The purpose of this study was to propose a systematic approach to validate a finite element model (FEM) of the human mandible and to investigate the effects of changing the geometry and orthotropic material properties on the FEM predictions. Thirty-eight variables affecting the material properties, boundary conditions, and the geometry of a FEM of a human mandible, including two dental implants, were systematically changed, creating a number of FEMs of the mandible. The effects of the variations were quantified as differences in the principal strain magnitudes modeled by the original FEM (gold standard), prior to the sensitivity analyses, and those generated by the changed FEMs. The material properties that had the biggest impact on the predicted cortical principal strain were the shear moduli (up to 31% in difference from the unchanged state), and the absence of cancellous bone (up to 34%). Alterations to the geometry of the mandibular cross section, such as an increase in corpus dimensions, had the greatest effect on principal strain magnitudes (up to 16%). Changes in the cortical thickness in relation to the width of the corpus section modified strain more than alterations to the corpus depth (14% and 5%, respectively). The relatively small difference (up to 13.5%) between the predicted and measured interimplant distances indicates the accuracy of the FEM. Changes in geometry and orthotropic material properties could induce significant changes in strain patterns. These values must therefore be chosen with care when using finite element techniques for predicting stresses, strains, and displacements.

Development of a three-dimensional finite element model of a human mandible containing endosseous dental implants. I. Mathematical validation and experimental verification.

The purpose of this study was to mathematically validate and clinically verify a finite element model (FEM) of the human mandible and to compare the functional deformation predicted by the model with that detected clinically. Mandibular surface strain, using 11 single strain gauges, and medial convergence (MC), using a custom-fabricated linear variable differential transformer (LVDT), were recorded in a dried human jaw. The mandible was treated with two endosseous implants, placed bilaterally in the premolar area, and mounted in a rig that simulated natural function of the jaw. Measurements were made in real time using a multichannel analogue/digital converter and a personal computer for data storage and analysis. A FEM of the mandible was constructed, using commercially available finite element software, based on CT scan images of the jaw. MC was predicted as the linear change in the orientation of the two implants in the horizontal plane. Predicted and measured values of MC ranged between 60 and 109 microm. The differences between the measured and predicted strain magnitudes were expressed as absolute percentages of the measured values and ranged between 3 and 18%. The limits of agreement between the predicted and measured strain values, as suggested by Bland and Altman (Lancet 1986; 1:307-310), were small enough for the predictions from the FEM to be considered clinically acceptable. The good agreement between the predicted and measured strain values indicates the accuracy of the present FEM. Finite element analysis is a powerful technique that provides a better insight into understanding the complex phenomena of mandibular functional deformation.

WITHDRAWN: Stereolithography and the use of pre-adapted or fabricated plates for accurate repair of maxillofacial defects.

This article has been withdrawn consistent with Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). The Publisher apologizes for any inconvenience this may cause.

Spine after solid organ transplantation in childhood: a clinical, radiographic, and magnetic resonance imaging analysis of 40 patients.

STUDY DESIGN: A cross-sectional study of the spine in 40 young adults after solid organ transplantation in childhood. OBJECTIVE: To evaluate the impact of organ transplantation and long-term immunosuppressive treatment on growing spine using magnetic resonance imaging (MRI). SUMMARY OF BACKGROUND DATA: A review of the current literature reveals no systematic evaluation of the spine after transplantation in childhood. METHODS: A total of 40 adult patients (mean age 22.1 years, range, 16.0-27.0), who received either kidney, liver, or heart transplant as children, were evaluated. Mean follow-up after transplantation was 11.2 years (range 3.0-18.0). All patients filled in a questionnaire, underwent an interview and physical examination, as well as had MRI of the spine. Standing spinal radiographs were taken from patients with a rib hump > or = 6 degrees. RESULTS: There were 8 (20%) patients who had a history of vertebral fracture. Eleven (28%) patients reported frequent back pain at rest. There were 15 (38%) patients who had scoliosis > 10 degrees (range 10 degrees -69 degrees ). On MRI, narrowed disc spaces were noted in 32 (80%) patients, and irregular endplates were noted in 24 (60%). There were 14 (35%) patients who had at least 1 compressed or wedged vertebra (> 20%). Patients treated for acute rejection had wedged vertebrae, speckled or black disc spaces, and irregular endplates more often than patients without rejections. Males had wedged vertebrae more often than females (P = 0.0067). CONCLUSIONS: Back pain, scoliosis, wedged vertebrae, and narrowed, degenerated disc spaces are common after solid organ transplantation in childhood.

Avascular bone necrosis of the hip joint after solid organ transplantation in childhood: a clinical and MRI analysis.

BACKGROUND: Aseptic osteonecrosis is a well-known complication after solid organ transplantation in adults. The occurrence of osteonecrosis in growing age has been studied after kidney transplantation, but no systematic evaluation of the joints has been reported after heart or liver transplantation in childhood. METHODS: A total of 196 children--93% of patients surviving kidney, liver and heart transplantation in Finland--participated in a cross-sectional survey. All children underwent a detailed clinical examination and filled out a questionnaire on musculoskeletal symptoms. Radiographs were taken in case of joint pain or abnormal clinical findings. In addition, magnetic resonance imaging (MRI) from the hips was taken on a random basis from 34 adult patients transplanted as a child. The mean follow-up time of all patients after transplantation was 9.2 years (range, 2.4 to 20.5 years). RESULTS: Twenty-eight (14%) patients reported prolonged joint or limb pain without previous trauma. Specific etiology for the limb pain was not found in 10 (5.1%) patients. Osteonecrosis seen in radiographs or MRI was noted in seven (3.6%) patients, of which three had received kidney, three liver, and one heart graft. Femoral head was affected in five patients, as well as talus bilaterally in one patient and lateral femoral condyle in one patient. All patients were older than 12 years at the time of diagnosis of the osteonecrosis. MRI of the hips of 34 randomly selected patients showed only one asymptomatic necrosis of the femoral head. CONCLUSIONS: Symptomatic osteonecrosis of the hip is uncommon after solid organ transplantation in childhood using the current immunosuppressive medications.

Biomechanics of the mandible part I: measurement of mandibular functional deformation using custom-fabricated displacement transducers.

PURPOSE: The purpose of this study was to measure corporal approximation, dorsoventral shear, and corporal rotation in edentulous subjects treated with dental implants, during normal mandibular movements. MATERIALS AND METHODS: Three patterns of jaw deformation (corporal approximation [CA], corporal rotation [CR], and dorsoventral [DV] shear) were measured using custom-fabricated displacement transducers in 12 edentulous subjects who had been treated with dental implants. Measurements were made in real time using a multichannel analogue/digital converter and a personal computer for data storage and analysis. Corporal approximation was measured as the linear change in the orientation of the 2 implants in the horizontal plane. Corporal rotation was recorded as a relative rotation of the right and left mandibular bodies projected into the frontal plane, and dorsoventral shear as the relative rotation of the 2 implants projected onto the median sagittal plane. RESULTS: All 3 patterns of mandibular deformation occurred concurrently and immediately on commencement of jaw movement. Different jaw movements produced different patterns of mandibular deformation. The highest values of jaw deformation were recorded during protrusion. CA ranged between 11.0 microm and 57.8 microm. Corporal rotation and DV shear ranged between 0.4 degrees and 2.8 degrees . CONCLUSION: This clinical study shows and measures 3 different and concurrent patterns of jaw deformation, during normal mandibular movements, using custom fabricated displacement transducers. The transducers may have a potential for routine clinical applications.

Incidence and predictors of fractures in children after solid organ transplantation: a 5-year prospective, population-based study.

UNLABELLED: In this population-based prospective follow-up study, children undergoing solid organ transplantation had a highly elevated risk for fractures: The incidence of all fractures was 6-fold higher (92 versus 14 fractures/1000 persons/year; p < 0.001) and vertebral fractures was 160-fold higher (57 versus 0.35 fractures/1000 persons/year; p < 0.001) in the study group compared with the control population. Thus, screening of vertebral fractures at regular intervals is recommended, and preventive strategies should be studied. INTRODUCTION: The incidence and predictors of fractures after solid organ transplantation are not well documented in the pediatric age group. MATERIALS AND METHODS: A total of 196 children, which is 93% of patients surviving kidney, liver, and heart transplantation in our country, participated in a retrospective chart review at enrollment followed by a 5-year prospective follow-up study between January 1999 and December 2004. Hospital and medical records were reviewed. All children underwent clinical examinations and answered questionnaires concerning fracture history at the beginning and at the end of the prospective follow-up. Radiographs of the thoracic and lumbar spine were obtained. The fracture incidence was compared with data obtained from public health registries. RESULTS: Seventy-five (38%) of the transplant patients suffered from a total of 166 fractures after organ transplantation. The incidence of all fractures was 6-fold higher (92 versus 14 fractures/1000 persons/year; p < 0.001) and vertebral fractures was 160-fold higher (57 versus 0.35 fractures/1000 persons/year; p < 0.001) in the study group compared with the control population. The age- and sex-adjusted hazard ratios (95% CI) were 61.3 (40.7-92.4) for vertebral, 17.9 (8.96-35.8) for symptomatic vertebral, 0.99 (0.65-1.50) for nonvertebral, and 2.90 (2.25-3.73) for all fractures in the patients compared with the control population. In a multivariate analysis, older age (hazard ratio [95% CI]; 2.02 [1.07-3.83]), male sex (2.15 [1.22-3.81]), liver transplantation (1.78 [1.01-3.14]), and fractures before transplantation (2.02 [0.92-4.47]) were the most significant independent risk factors. CONCLUSIONS: Children undergoing solid organ transplantation have a highly elevated risk for fractures. Screening of vertebral fractures at regular intervals is recommended, and preventive strategies should be studied.

Does gender affect outcome of surgery in adolescent idiopathic scoliosis?

STUDY DESIGN: A retrospective follow-up study comparing 2 matched groups. OBJECTIVE: To compare long-term results of operative treatment of adolescent idiopathic scoliosis (AIS) between males and females matched for age, curve magnitude and type, and the instrumentation used. SUMMARY OF BACKGROUND DATA: It has been suggested that in AIS, the spine is more rigid in males than in females, because brace treatment fails to halt progression of the curves in males. However, there are no studies comparing the results of surgical treatment of AIS between males and females. METHODS: Thirty male and female pairs were matched for age (+/-1 year), major curve magnitude (+/-5 degrees), curve type according to the King classification, and the instrumentation used (Harrington in 11 pairs, Cotrel-Dubousset in 9 pairs, and Universal Spine System in 10 pairs). The mean age at the time of operation was 16.2 +/- 2.6 years for the males and 15.5 +/- 2.3 years for the females. The mean follow-up times were 14.3 years (range 6.7-23.0 years) and 14.1 year (range 6.4-23.7 years), respectively. Radiographs were obtained presurgery and after surgery, at the 2-year follow-up assessment, and at the final follow-up visit. In addition, a physical examination was performed, and the Scoliosis Research Society (SRS) questionnaire was completed. Spine mobility and nondynamometric trunk strength were measured at the final follow-up visit. RESULTS: Before surgery, the mean Cobb angle of the thoracic curve was 55 degrees (range 42-83 degrees) in the males and 56 degrees (range 43-80 degrees) in the females. In bending radiographs, the major curve reduced significantly more in females than in males (P = 0.027). The mean angles of the thoracic and lumbar curves were similar at all follow-up visits. The final correction of the thoracic curves was 30% (range -19-65%) in the males and 33% (range -7-71%) in the females (not significant). No significant difference was observed in thoracic kyphosis or lumbar lordosis between the study groups at the final follow-up. The total SRS questionnaire score averaged 96 (range 66-113) in the males and 95 (range 75-108) in the females. None of the males and 2 of the females reported back pain often or very often in the questionnaire. Nondynamometric trunk strength measurements corresponded with reference values, on average, and were similar in both groups. Abnormal trunk side bending tended to be more common in the males than in the females (43% vs. 23%, P = 0.10, not significant). CONCLUSIONS: Curves in males appear to be more rigid than in females with AIS. However, posterior surgery for AIS provides similar short and long-term results in males and females.

Harrington and Cotrel-Dubousset instrumentation in adolescent idiopathic scoliosis. Long-term functional and radiographic outcomes.

BACKGROUND: Previous studies have shown that the long-term clinical outcome does not correlate with the radiographic outcome in patients treated with Harrington instrumentation for adolescent idiopathic scoliosis. Cotrel-Dubousset instrumentation has been reported to provide better correction radiographically, but it is unclear whether it provides better long-term clinical or functional outcomes. We are not aware of any long-term studies comparing Harrington and Cotrel-Dubousset instrumentation. METHODS: Seventy-eight patients in whom adolescent idiopathic scoliosis was treated with Harrington instrumentation and fifty-seven in whom it was treated with Cotrel-Dubousset instrumentation participated in this study. The mean duration of follow-up was 20.8 years for the Harrington instrumentation group and 13.0 years for the Cotrel-Dubousset instrumentation group. The mean age at the time of follow-up was thirty-six years and twenty-eight years, respectively. Radiographs were made preoperatively and at the two-year and final follow-up examinations. The Scoliosis Research Society questionnaire was completed, a physical examination was performed, and spinal mobility and non-dynamometric trunk strength were measured at the final follow-up visit. RESULTS: The mean preoperative Cobb angle of the thoracic curves was 53 degrees in the Harrington instrumentation group and 55 degrees in the Cotrel-Dubousset instrumentation group. The mean numbers of vertebrae included in the instrumentation were 10.7 and 9.9, respectively. At the two-year follow-up evaluation, the mean postoperative Cobb angles were 38 degrees and 25 degrees, respectively (p < 0.0001). At the final follow-up evaluation, the mean angles were 45 degrees and 32 degrees (p < 0.0001). No significant difference in thoracic kyphosis or lumbar lordosis was observed between the study groups at the final follow-up evaluation. The average score on the Scoliosis Research Society questionnaire was 97 points in both groups. Measurements of non-dynamometric trunk strength corresponded with age and sex-adjusted reference values, on the average, but patients with Cotrel-Dubousset instrumentation performed significantly better in the squatting test (p = 0.010). Abnormal lumbar extension and trunk side-bending were significantly more common in the Harrington instrumentation group (p = 0.050 and p = 0.0061, respectively). Complications were recorded for nine (12%) of the patients treated with Harrington instrumentation and fifteen (26%) of those treated with Cotrel-Dubousset instrumentation (p = 0.027). CONCLUSIONS: Cotrel-Dubousset instrumentation yielded better long-term functional and radiographic outcomes in patients with adolescent idiopathic scoliosis than did Harrington instrumentation. However, complications were more common in the Cotrel-Dubousset instrumentation group.

Total knee arthroplasty in patients with diastrophic dysplasia.

BACKGROUND: Diastrophic dysplasia results in severe disproportionate short stature, generalized joint deformities, and early osteoarthritis. The knee joint often has an abnormal valgus position and is unstable, and degeneration of all joint compartments occurs, even during growth. The purpose of our study was to evaluate the clinical and radiographic results of total knee arthroplasty in a series of patients with diastrophic dysplasia. METHODS: Between February 1992 and March 2000, twenty-one primary total knee arthroplasties were performed on fourteen consecutive patients with severe osteoarthritis due to diastrophic dysplasia. The patients were followed prospectively with clinical examinations, determination of the Hungerford knee scores, and radiographs. Preoperatively, ten knees had chronic dislocation of the patella. The mean duration of follow-up was 3.4 years. RESULTS: The mean Hungerford knee pain and total scores improved from 5.8 points and 46 points preoperatively to 50 points and 83 points, respectively, at the final follow-up examination (p < 0.001 for both comparisons). Two knees required a distal femoral corrective osteotomy because of metaphyseal angulation. None of the total knee arthroplasties had to be revised during the follow-up period. Six complications were recorded. CONCLUSIONS: Total knee arthroplasty substantially improved the function of patients with diastrophic dysplasia. Additional peripatellar procedures were commonly needed, and complications were frequent.

Effect of continuing or finishing high-level sports on airway inflammation, bronchial hyperresponsiveness, and asthma: a 5-year prospective follow-up study of 42 highly trained swimmers.

BACKGROUND: Mild eosinophilic airway inflammation and bronchial hyperresponsiveness-ie, mild asthma-have been shown to affect a high proportion of endurance athletes. The persistence of airway inflammation, bronchial hyperresponsiveness, and asthma in this population is not known, however, inasmuch as follow-up studies of athletes' asthma have not been performed. OBJECTIVE: The purpose of this study was to investigate effect of finishing high-level sports on airway inflammation, bronchial hyperresponsiveness, and asthma. METHODS: Forty-two elite competitive swimmers, most of them from the Finnish national team (37/42; 88%), were followed for 5 years in a prospective manner. All of the swimmers completed questionnaires and underwent resting spirometry, histamine challenge testing, and skin prick tests at baseline and at follow-up. Twenty-nine swimmers (69%) also gave induced sputum samples on both occasions. Sixteen (38%) of the swimmers had continued their competitive careers during follow-up (active swimmers), but 26 (62%) had stopped competing more than 3 months before the follow-up examination (past swimmers). RESULTS: Bronchial responsiveness was increased in 7 (44%) of the 16 active swimmers at baseline and in 8 (50%) of the 16 active swimmers at follow-up; it was increased in 8 (31%) of the 26 past swimmers at baseline and in 3 (12%) of the 26 past swimmers at follow-up (McNemar test, P =.025). The difference in the change in bronchial hyperresponsiveness between the study groups was significant (likelihood ratio test, P =.023). Current asthma (defined as bronchial hyperresponsiveness and exercise-induced bronchial symptoms monthly) was observed in 5 (31%) of the active swimmers at baseline and in 7 (44%) of the active swimmers at follow-up; of the past swimmers, it occurred in 6 (23%) at baseline and in 1 (4%) at follow-up (McNemar test, P =.025). The difference in the change in current asthma between the study groups was significant (likelihood ratio test, P =.0040). The sputum differential cell counts of eosinophils and lymphocytes increased significantly during the follow-up period in the active swimmers (Wilcoxon signed rank sum test; P =.033 and P =.0029, respectively); in the past swimmers, the sputum differential cell counts of eosinophils tended to decrease during the follow-up period (P =.17), whereas the differential cell counts of lymphocytes did not change significantly. The changes in the sputum differential cell counts of eosinophils between the study groups differed significantly (Mann-Whitney U test, P =.019). CONCLUSION: In swimmers who had stopped high-level training, bronchial hyperresponsiveness and asthma attenuated or even disappeared. Mild eosinophilic airway inflammation was aggravated among highly trained swimmers who remained active during the 5-year follow-up. Our results suggest that athletes' asthma is partly reversible and that it may develop during and subside after an active sports career.

Comparison of long-term functional and radiologic outcomes after Harrington instrumentation and spondylodesis in adolescent idiopathic scoliosis: a review of 78 patients.

STUDY DESIGN: A retrospective follow-up study of adolescent idiopathic scoliosis after Harrington instrumentation and spondylodesis was conducted. OBJECTIVE: To correlate radiographic parameters with the Scoliosis Research Society questionnaire in terms of patient outcome, clinical findings, spine mobility, and trunk strength measurements. SUMMARY OF BACKGROUND DATA: Previous studies have shown that long-term radiologic correction can be achieved with Harrington instrumentation. It seems, however, that radiologic correction does not correlate with patient outcome. There are no previous studies on long-term results of functional outcome, including spine mobility and trunk strength measurements, after operative treatment of adolescent idiopathic scoliosis, as compared with findings in the normal population. METHODS: Of 98 consecutive patients who underwent surgery with Harrington distraction rod and posterior spondylodesis in 1979, 78 (80%) (11 males; mean age, 36 years) participated in the study. The average follow-up period was 20.8 years (range, 19.1-22.4 years). Radiographs were obtained before surgery, at the 2-year follow-up assessment, and at the 20-year follow-up assessment. Additionally, physical examination was performed, and the Scoliosis Research Society questionnaire was completed. Spine mobility and nondynamometric trunk strength measurements were obtained at the 20-year follow-up assessment. RESULTS: The mean Cobb angle of the instrumented thoracic curve was 53 degrees +/- 10 degrees before surgery, and 38 degrees +/- 11 degrees at the 2-year follow-up assessment. At the 20-year follow-up assessment, the mean angle was 45 degrees +/- 12 degrees. Degenerative changes in the noninstrumented lumbar spine (sclerosis of facets, endplate sclerosis, osteophyte formation) were noted in 17 patients (22%). Ten patients (13%) reported having low back pain often or very often at rest according to the Scoliosis Research Society questionnaire. No correlation was found between the Cobb angle of the thoracic or lumbar curves at follow-up assessment and the Scoliosis Research Society total score or back pain indexes. Neither was any association found between the Scoliosis Research Society total score and the spondylodesis fusion level. However, the magnitude of the thoracic curve at follow-up assessment showed a significant inverse correlation with the scores for Scoliosis Research Society questions about cosmetic aspects. The nondynamometric trunk strength measurements corresponded with the reference values, on the average, but did not show any correlation with the magnitude of the thoracic or lumbar curves or with the Scoliosis Research Society total score or back pain indexes. Spine mobility, especially trunk side bending, was diminished in 59% of the patients, and did not correlate with the Scoliosis Research Society total score or individual indexes. CONCLUSIONS: In patients with adolescent idiopathic scoliosis who undergo surgery with Harrington instrumentation, the overall long-term clinical outcome does not correlate with the radiologic outcome. However, a significant inverse correlation was found between the magnitude of the primary thoracic curve at follow-up assessment and the scores for questions on cosmetic matters in the Scoliosis Research Society questionnaire. Spine mobility is diminished as a result of spondylodesis, but the patients perform, on the average, as well as the normal population in nondynamometric trunk strength measurements.