Long-term mortality and causes of death among patients with a total knee prosthesis in primary osteoarthritis.

BACKGROUND: Short and midterm mortality of patients with osteoarthritis (OA) who have undergone total knee arthroplasty (TKA) is generally lower than that of the general population. Due to an increasing number of young patients who undergo TKA the expected lifetime of these patients is increasing. The purpose of this study was to assess the causes of death and long-term mortality among Finnish TKA patients. METHODS: Standardized mortality ratios (SMRs) for total and site specific causes of death were calculated for 9443 TKA patients operated on in 1980 to 1996 for OA and followed until 2012. RESULTS: The mean follow-up time was 14 years (maximum 33 years). During follow-up, 77% of the patients had died. The all-cause SMR was 1.00. It was significantly lower than in the reference population (SMR 0.73) during the first 10 years after operation, but higher during the next 10 years (SMR 1.23), and even more after 20 years (SMR 1.95). The SMR for cardiovascular mortality was 1.03 and accounted for 52% of all deaths. Significant excess mortality was observed in diseases of the digestive tract (SMR 1.29). Deaths due to cardiovascular diseases, Alzheimer's disease and dementia comprised 68% of all deaths that took place 10 years or later after TKA. CONCLUSIONS: The mortality of TKA patients with OA is significantly reduced during the first 10 postoperative years but exceeds the mortality of the general population after that. This trend should be taken into account when young patients undergo a TKA. LEVEL OF EVIDENCE: Observational study, III.

Cancer incidence and cause-specific mortality in patients with metal-on-metal hip replacements in Finland.

BACKGROUND AND PURPOSE: Metal-on-metal hip implants have been widely used, especially in the USA, Australia, England and Wales, and Finland. We assessed risk of death and updated data on the risk of cancer related to metal-on-metal hip replacements. PATIENTS AND METHODS: A cohort of 10,728 metal-on-metal hip replacement patients and a reference cohort of 18,235 conventional total hip replacement patients were extracted from the Finnish Arthroplasty Register for the years 2001-2010. Data on incident cancer cases and causes of death until 2011 were obtained from the Finnish Cancer Registry and Statistics Finland. The relative risk of cancer and death were expressed as standardized incidence ratio (SIR) and standardized mortality ratio (SMR). SIR/SIR ratios and SMR/SMR ratios, and Poisson regression were used to compare the cancer risk and the risk of death between cohorts. RESULTS: The overall risk of cancer in the metal-on-metal cohort was not higher than that in the non-metal-on-metal cohort (RR = 0.91, 95% CI: 0.82-1.02). The risk of soft-tissue sarcoma and basalioma in the metal-on-metal cohort was higher than in the non-metal-on-metal cohort (SIR/SIR ratio = 2.6, CI: 1.02-6.4 for soft-tissue sarcoma; SIR/SIR ratio = 1.3, CI: 1.1-1.5 for basalioma). The overall risk of death in the metal-on-metal cohort was less than that in the non-metal-on-metal cohort (RR = 0.78, CI: 0.69-0.88). INTERPRETATION: The overall risk of cancer or risk of death because of cancer is not increased after metal-on-metal hip replacement. The well-patient effect and selection bias contribute substantially to the findings concerning mortality. Arthrocobaltism does not increase mortality in patients with metal-on-metal hip implants in the short term. However, metal-on-metal hip implants should not be considered safe until data with longer follow-up time are available.

Risk of cancer with metal-on-metal hip replacements: population based study.

OBJECTIVE: To assess the risk of cancer associated with modern primary metal-on-metal hip replacements. DESIGN: Population based study. SETTING: Nationwide retrospective comparative register. PARTICIPANTS: 10,728 patients who underwent metal-on-metal total hip arthroplasty and 18,235 patients who underwent conventional metal-on-polyethylene, ceramic-on-polyethylene, and ceramic-on-ceramic total hip arthroplasty (the non-metal-on-metal cohort) in the Finnish Arthroplasty Register 2001-10. Data on cancer cases up to 2010 for these cohorts were extracted from the Finnish Cancer Registry. MAIN OUTCOME MEASURES: The relative risk of cancer was expressed as the ratio of observed to expected number of cases from the Finnish population--that is, the standardised incidence ratio. The relative risk of cancer in the metal-on-metal cohort compared with the non-metal-on-metal cohort was estimated with analyses of these ratios and Poisson regression. RESULTS: The overall risk of cancer in patients with metal-on-metal hip implants was similar to that in the Finnish population (378 observed v 400 expected, standardised incidence ratio 0.95, 95% confidence interval 0.85 to 1.04). The overall risk of cancer in patients with metal-on-metal hip implants was also no higher than in patients who had received non-metal-on-metal hip implants (relative risk 0.92, 0.81 to 1.05). CONCLUSIONS: Metal-on-metal hip replacements are not associated with an increased overall risk of cancer during a mean follow-up of four years.

Patellofemoral osteoarthritis in patients with operative treatment for patellar dislocation: a magnetic resonance-based analysis.

PURPOSE: the clinical role of patellofemoral (PF) osteoarthrosis (OA) in the outcome after PF stabilizing surgery is poorly understood. The study hypothesis was that PF cartilage lesions and OA are associated with a poor long-term outcome after PF stabilizing surgery. METHODS: the study cohort included thirty-seven patients who underwent PF stabilizing surgery by traditional nonanatomic procedures and were evaluated a minimum of 10 years (range 10-21) after surgery. PF OA was assessed by magnetic resonance (MR) images and plain radiographs obtained at follow-up. Median patient age at follow-up was 33 years (29-43). RESULTS: at the final follow-up, PF full-thickness cartilage lesions were observed on MR images in 29 (78%) patients. Only 46% of the patients reported satisfaction at follow-up, and dissatisfaction was associated with PF OA (full-thickness articular cartilage loss on MR images; P = 0.022). Especially high incidence, 89%, of medial patellar facet cartilage lesions were found among the patients dissatisfied with the result (16/18 patients) (n.s.). Eight (22%) of the 37 patients reported recurrent patellar instability episodes at follow-up. Median Kujala score was 83 points (range 55-98). CONCLUSION: patellofemoral OA is a significant long-term risk of nonanatomic surgery for patellar instability and has a greater impact on subjective outcome than residual instability more than 10 years after surgery.

Surgical Technique for Treating Acute Ruptures of the Lateral Ligament Complex of the Ankle.

INTRODUCTION: Surgical treatment of an acute lateral ligament rupture is occasionally warranted. STEP 1 INCISION: Make a skin incision from the anterior aspect of the fibula and curve it inferiorly and posteriorly. STEP 2 REPAIR: Repair the ligaments with absorbable sutures; if there is bone avulsion, pass the sutures through drill holes or use a suture anchor. STEP 3 CLOSURE: Close the wound in layers using absorbable sutures. STEP 4 POSTOPERATIVE CARE: Cast immobilization for four weeks is followed by orthosis use for two weeks; muscle exercises are initiated on the first postoperative day. RESULTS: In our previous randomized controlled trial comparing surgical and functional treatment of acute ruptures of the lateral ligament complex of the ankle, the mean score on the Performance Test Protocol and Scoring Scale for the Evaluation of Ankle Injuries was 83 ± 11 points in the surgical treatment group and 75 ± 13 points in the functional treatment group (mean difference: 8.3 points; 95% confidence interval: -0.03 to 16.6 points). WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Surgical versus functional treatment for acute ruptures of the lateral ligament complex of the ankle in young men: a randomized controlled trial.

BACKGROUND: Some have recommended surgical treatment of Grade-III lateral ligament injuries in very active individuals with high functional demands on the ankle. The purpose of this study was to establish whether surgery provides better long-term results than functional treatment for acute ruptures of the lateral ligaments of the ankle. METHODS: Physically active Finnish men (mean age, 20.4 years) with an acute Grade-III lateral ligament rupture of the ankle were randomly allocated to surgical (n = 25) or functional (n = 26) treatment. Ligament injury was confirmed with stress radiographs. Surgical treatment comprised suture repair of the injured ligament(s) within the first week after injury. A below-the-knee plaster cast was worn for six weeks with full weight-bearing. Functional treatment consisted of the use of an Aircast ankle brace for three weeks. The main outcome measures included final follow-up examinations, calculation of an ankle score, stress radiographs, and magnetic resonance imaging scans. RESULTS: Fifteen (60%) of twenty-five surgically treated patients and eighteen (69%) of twenty-six functionally treated patients returned for long-term follow-up (mean duration, fourteen years). All patients in both groups had recovered their preinjury activity level and reported that they could walk and run normally. The prevalence of reinjury was one of fifteen in the surgical group and seven of eighteen in the functional treatment group (risk difference: 32%; 95% confidence interval: 6% to 58%). The mean ankle score did not differ significantly between the groups (mean difference: 8.3 points; 95% confidence interval: -0.03 to 16.6 points). Stress radiographs revealed no difference between groups with regard to the mean anterior drawer (-1 mm in the surgical group and 0 mm in the functional treatment group; mean difference: 0.7 mm; 95% confidence interval: -1.4 to 2.7 mm) or mean tilt angle (0° in both groups; mean difference: 0.1°; 95% confidence interval: -3.2° to 3.5°). Grade-II osteoarthritis was observed on magnetic resonance images of four of the fifteen surgically treated patients and in none of the eighteen functionally treated patients (risk difference: 27%; 95% confidence interval: 4% to 49%). CONCLUSIONS: These findings indicate that, in terms of recovery of the preinjury activity level, the long-term results of surgical treatment of acute lateral ligament rupture of the ankle correspond with those of functional treatment. Although surgery appeared to decrease the prevalence of reinjury of the lateral ligaments, there may be an increased risk for the subsequent development of osteoarthritis.

Long-term outcome after surgical treatment of unresolved osgood-schlatter disease in young men: surgical technique.

BACKGROUND: Surgical treatment of Osgood-Schlatter disease is occasionally warranted, but its long-term prognosis remains poorly investigated. We studied the rate of occurrence of surgical treatment of unresolved Osgood-Schlatter disease as well as the clinical course, radiographic characteristics, and long-term outcomes after that treatment in a large population of military recruits. METHODS: During a thirteen-year period, 178 consecutive recruits underwent surgery for unresolved Osgood-Schlatter disease, and 107 of them (117 knees) who met the inclusion criteria participated in a follow-up examination. We obtained data from the original medical records and radiographs as well as follow-up information from physical and radiographic examinations, interviews, and questionnaires to determine functional outcomes. RESULTS: The rate of occurrence of surgically treated unresolved Osgood-Schlatter disease was forty-two per 100,000 military recruits. The median age at the onset of symptoms was fifteen years. After a median duration of follow-up of ten years after the surgery, ninety-three patients (87%) reported no restrictions in everyday activities or at work and eighty (75%) had returned to their preoperative level of sports activity. The median modified Kujala score was 95 points, and the median visual analog score for pain was 7 mm. Forty-one patients (38%) reported a complete absence of pain when kneeling. Six patients had experienced minor postoperative complications, and two had undergone a reoperation for the treatment of the Osgood-Schlatter disease. After resection, the mean tibial tuberosity thickness decreased by 47%. The mean Insall-Salvati index was 1.0 preoperatively and 1.09 postoperatively (p = 0.003), and the corresponding mean Blackburne-Peel indexes were 0.85 and 0.95 (p = 0.003). With the numbers studied, the symptom duration, surgical methods, and radiographic indexes were not found to have an effect on the outcome of surgery. CONCLUSIONS: In the great majority of young adults, the functional outcome of surgical treatment of unresolved Osgood-Schlatter disease is excellent or good, the residual pain intensity is low, and postoperative complications or subsequent reoperations are rare.

A retrospective comparative study of mortality and causes of death among patients with metal-on-metal and metal-on-polyethylene total hip prostheses in primary osteoarthritis after a long-term follow-up.

BACKGROUND: All patients with total hip arthroplasty (THA), especially those with metal-on-metal (MM) THA, are exposed to metallic particles and ions, which may cause total or site-specific mortality. We analyzed the causes of total and site-specific mortality among a cohort of patients with MM and with metal-on-polyethylene (MP) THA after a long follow-up time. METHODS: Standardized mortality ratios (SMR) of total and site-specific causes of death were calculated for 579 patients with MM (McKee-Farrar) and 1585 patients with MP (Brunswik, Lubinus) THA for primary osteoarthritis. RESULTS: Mean follow-up time was 17.9 years for patients with MM and 16.7 years for patients with MP. Overall SMR was 0.95 for the MM cohort and 0.90 for the MP cohort, as compared to the normal population. Both cohorts showed significantly decreased mortality for the first decade postoperatively, equal mortality over the next 10 years, and significantly increased mortality after 20 years. Patients with MM THA had higher cancer mortality (SMR 1.01) than those with MP THA (SMR 0.66) during the first 20 years postoperatively, but not thereafter. CONCLUSION: Both MM and MP prostheses are safe based on total and site-specific mortality of recipients during the first 20 postoperative years in comparison with the general population.

Cancer risk is not increased after conventional hip arthroplasty.

BACKGROUND AND PURPOSE: Wear debris from conventional total hip arthroplasty (THA) induces chromosomal aberrations and DNA damage, which may promote cancerogenesis. A long latent period is required for solid tumors. We therefore re-analyzed a large THA cohort for cancer. PATIENTS AND METHODS: We updated a cohort of 24,636 patients with primary osteoarthritis and metal-on-polyethylene THA who had been entered in the Finnish Arthroplasty Register between 1980 and 1995, and linked it to the Finnish Cancer Registry for cancer risk assessment up to 2005. The mean follow-up time was 13 years. The numbers of cancer cases observed were compared with expected rates based on incidence in the general population. RESULTS: The standardized incidence ratio (SIR) for the whole follow-up period was 0.95 (95% confidence interval (CI): 0.92-0.97). After 10 years of follow-up, the SIR was equal to that in the normal population (SIR = 0.98, 95% CI: 0.94-1.03). Incidence of lung cancer was low throughout the follow-up time and that of prostate cancer was slightly elevated. The incidence rates for all other forms of cancer did not deviate significantly from those in the normal population. INTERPRETATION: We found no increased cancer risk in patients with conventional THA after an average of 13 years and up to 25 years of follow-up.

Long-term outcome after surgical treatment of unresolved Osgood-Schlatter disease in young men.

BACKGROUND: Surgical treatment of Osgood-Schlatter disease is occasionally warranted, but its long-term prognosis remains poorly investigated. We studied the rate of occurrence of surgical treatment of unresolved Osgood-Schlatter disease as well as the clinical course, radiographic characteristics, and long-term outcomes after that treatment in a large population of military recruits. METHODS: During a thirteen-year period, 178 consecutive recruits underwent surgery for unresolved Osgood-Schlatter disease, and 107 of them (117 knees) who met the inclusion criteria participated in a follow-up examination. We obtained data from the original medical records and radiographs as well as follow-up information from physical and radiographic examinations, interviews, and questionnaires to determine functional outcomes. RESULTS: The rate of occurrence of surgically treated unresolved Osgood-Schlatter disease was forty-two per 100,000 military recruits. The median age at the onset of symptoms was fifteen years. After a median duration of follow-up of ten years after the surgery, ninety-three patients (87%) reported no restrictions in everyday activities or at work and eighty (75%) had returned to their preoperative level of sports activity. The median modified Kujala score was 95 points, and the median visual analog score for pain was 7 mm. Forty-one patients (38%) reported a complete absence of pain when kneeling. Six patients had experienced minor postoperative complications, and two had undergone a reoperation for the treatment of the Osgood-Schlatter disease. After resection, the mean tibial tuberosity thickness decreased by 47%. The mean Insall-Salvati index was 1.0 preoperatively and 1.09 postoperatively (p = 0.003), and the corresponding mean Blackburne-Peel indexes were 0.85 and 0.95 (p = 0.003). With the numbers studied, the symptom duration, surgical methods, and radiographic indexes were not found to have an effect on the outcome of surgery. CONCLUSIONS: In the great majority of young adults, the functional outcome of surgical treatment of unresolved Osgood-Schlatter disease is excellent or good, the residual pain intensity is low, and postoperative complications or subsequent reoperations are rare.

Femoral avulsion of the medial patellofemoral ligament after primary traumatic patellar dislocation predicts subsequent instability in men: a mean 7-year nonoperative follow-up study.

BACKGROUND: The clinical relevance of medial patellofemoral ligament (MPFL) injury location in primary patellar dislocation has not been studied. HYPOTHESIS: Prognosis after primary traumatic patellar dislocation may vary by MPFL injury location. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The initial magnetic resonance imaging (MRI) findings in 53 patients with identical nonoperative management were retrospectively analyzed for medial restraint injuries. The MPFL injury sites were classified as follows: femoral, midsubstance, and patellar. Magnetic resonance imaging was used to assess initial and control articular cartilage lesions in the patellofemoral joint. After a mean follow-up of 7 years, 42 patients were evaluated for redislocations, subjective symptoms, and functional limitations. RESULTS: Based on the initial MRIs, MPFL rupture was classified as femoral in 35 patients, midsubstance in 11, and patellar in 7. At follow-up, 15 patients reported an unstable patella (13 femoral, 1 patellar, 1 midsubstance; P = .01) and 9 reported patellar redislocations (8 femoral, 1 midsubstance; P = .05). The proportion of patients who regained their preinjury activity level was significantly smaller among those with femoral MPFL injury than among those with midsubstance or patellar MPFL injury (P = .05). The median Kujala score was as follows: 90 for femoral, 91 for patellar, and 96 for midsubstance (P = .76). Control MRI showed full-thickness patellofemoral cartilage lesions in 50% of the patients, unrelated to MPFL injury location. CONCLUSION: An MPFL avulsion at the femoral attachment in primary traumatic patellar dislocations predicts subsequent patellar instability. The authors suggest that MPFL injury location be taken into account when planning treatment of primary traumatic patellar dislocation.

Treatment with and without initial stabilizing surgery for primary traumatic patellar dislocation. A prospective randomized study.

BACKGROUND: There is no consensus about the management of acute primary traumatic patellar dislocation in young physically active adults. The objective of this study was to compare the clinical outcomes after treatment with and without initial stabilizing surgery for primary traumatic patellar dislocation in young adults. METHODS: Forty young adults, thirty-seven men and three women with a median age of twenty years (range, nineteen to twenty-two years), who had an acute primary traumatic patellar dislocation were randomly allocated to be treated with initial surgical stabilization (eighteen patients, with each receiving one of two types of initial stabilizing procedures) or to be managed with an orthosis (twenty-two patients, including four who had osteochondral fragments removed arthroscopically). After a median of seven years, thirty-eight patients returned for a follow-up examination. Redislocations, subjective symptoms, and functional limitations were evaluated. Radiographs and magnetic resonance images were obtained at the time of randomization, and twenty-nine (76%) patients underwent magnetic resonance imaging at the time of final follow-up. RESULTS: A hemarthrosis as well as injuries of the medial retinaculum and the medial patellofemoral ligament were found on magnetic resonance imaging in all patients at the time of randomization. During the follow-up period, six of the twenty-one nonoperatively treated patients and none of the seventeen patients treated with surgical stabilization had a redislocation (p = 0.02). Four nonoperatively treated patients and two patients treated with surgical stabilization reported painful patellar subluxation. The median Kujala scores were 91 points for the surgically treated patients and 90 points for the nonoperatively treated patients. Thirteen patients in the surgically treated group and fifteen in the nonoperatively treated group regained their former physical activity level. At the time of follow-up, a full-thickness patellofemoral articular cartilage lesion was detected on magnetic resonance imaging in eleven patients; the lesions were considered to be unrelated to the form of treatment. CONCLUSIONS: In a study of young, mostly male adults with primary traumatic patellar dislocation, the rate of redislocation for those treated with surgical stabilization was significantly lower than the rate for those treated without surgical stabilization. However, no clear subjective benefits of initial stabilizing surgery were seen at the time of long-term follow-up.

A mini-invasive adductor magnus tendon transfer technique for medial patellofemoral ligament reconstruction: a technical note.

Patellar dislocations are associated with injuries to the medial patellofemoral ligament (MPFL). Several techniques for MPFL reconstruction have been recently published with some disadvantages involved, including large skin incisions and donor site morbidity. Arthroscopic stabilizing techniques carry the potential of inadequate restoration of MPFL function. We present a minimally invasive technique for MPFL reconstruction using adductor magnus tendon autograft. This technique is easily performed, safe, and provides a stabilizing effect equal to current MPFL reconstructions. Skin incision of only 3-4 cm is located at the level of the proximal half of the patella. After identifying the distal insertion of the adductor magnus tendon, a tendon harvester is introduced to harvest the medial two-thirds of the tendon, while the distal insertion is left intact. The adductor magnus tendon is cut at 12-14 cm from its distal insertion and transferred into the patellar medial margin. Two suture anchors are inserted through the same incision at the superomedial aspect of the patella in the anatomic MPFL origin. The graft is tightened at 30 degrees knee flexion. Aftercare includes 4 weeks of brace treatment with restricted range of motion.

Incidence and trends of low back pain hospitalisation during military service--an analysis of 387,070 Finnish young males.

BACKGROUND: There is evidence that low back pain (LBP) during young adulthood and military service predicts LBP later in life. The purpose of this study was to investigate the incidence and trends of LBP hospitalisation among Finnish military conscripts. METHODS: All male conscripts performing their compulsory military service during 1990-2002 were included in the study population. Altogether 387,070 military conscripts were followed throughout their six-to-twelve-month service period. Data on LBP hospitalisations were obtained from the National Hospital Discharge Register. RESULTS: Altogether 7,240 LBP hospitalisations were identified among 5,061 (1.3%) male conscripts during the study period. The event-based incidence of LBP hospitalisation was 27.0 (95% confidence interval (CI): 25.7-28.2). In most cases, the diagnosis was unspecified LBP (n = 5,141, 71%) followed by lumbar disc disorders (n = 2,069, 29%). Hospitalisation incidence due to unspecified LBP was 19.1 per 1,000 person-years (95% CI: 18.3 to 20.4), and 7.8 per 1,000 person-years (95% CI: 6.7 to 8.3) due to lumbar disc disorders. The incidence of unspecified LBP remained unaltered, while hospitalisation due to lumbar disc disorders declined from 1993 onwards. CONCLUSION: Although conscripts accepted into military training pass physician-performed examinations as healthy, young adults, LBP hospitalisation causes significant morbidity during military service.

Arthroscopic surgery for primary traumatic patellar dislocation: a prospective, nonrandomized study comparing patients treated with and without acute arthroscopic stabilization with a median 7-year follow-up.

BACKGROUND: No data exist whether patients with primary traumatic patellar dislocation benefit from initial arthroscopic medial repair surgery. PURPOSE: To compare long-term outcomes of patients treated with acute arthroscopic stabilization for patellar dislocation with those treated nonoperatively except for removal of loose bodies. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The study group included 76 consecutive military recruits (72 men, 4 women), with a median age of 20 years (range, 19-22) at the time of dislocation. Thirty patients (group 1) underwent initial arthroscopic medial retinacular repair, and 46 patients (group 2) were treated without stabilizing surgery, including 11 who had osteochondral fragments arthroscopically removed. Patients with previous patellar dislocations or instability were excluded. Aftercare was identical in both groups. Redislocations, subjective symptoms, and functional limitations were evaluated after a median 7-year follow-up. RESULTS: Sixty-one (80%) patients participated in a follow-up examination. At final follow-up, 8 (23%) redislocations occurred in group 2 and 5 (19%) in group 1 (P = .84). Eight (23%) patients in group 2 and 3 (12%) in group 1 reported patellar subluxations (P = .18). In group 1, 81% regained their preinjury activity level compared with 56% in group 2 (P = .05). Functional outcomes were good in both groups (Kujala scores: 87 for group 1 and 90 for group 2) (P = .22). Regarding the presence of osteoarthritic characteristics in the patellofemoral joint, no statistically significant differences were found between the groups. CONCLUSIONS: Initial arthroscopic medial retinacular repair was not followed by improved patellar stability nor reduced incidence of redislocations compared with nonoperative (except for removal of loose bodies) treatment. Acute arthroscopic medial retinacular repair allowed patients to better regain preinjury activity level than in patients not undergoing retinacular repair. The decision to stabilize the patella by initial arthroscopic surgery should be made with caution.

Ligament reconstruction versus distal realignment for patellar dislocation.

UNLABELLED: Recently, medial patellofemoral ligament reconstruction has been emphasized for the treatment of patellar dislocation. This study compared the results of medial patellofemoral ligament reconstruction by adductor magnus tenodesis with distal patellar realignment in patients with recurrent patellar dislocation. Additionally, the development of patellofemoral osteoarthrosis was compared for these two procedures at a median 10-year followup. Between 1994 and 2000, 47 consecutive patients were treated for recurrent patellar dislocation by adductor magnus tenodesis (18 knees) or Roux-Goldthwait procedure (29 knees). Redislocations, subjective symptoms, and functional outcomes were evaluated. Magnetic resonance imaging was performed at followup. The incidence of patellar redislocation after surgery was 7% in the adductor magnus group and 14% in the Roux-Goldthwait group. Median Kujala scores were 88 for the adductor magnus group and 86 for the Roux-Goldthwait group. Magnetic resonance imaging revealed patellofemoral articular cartilage lesions in 22 knees (73.3%) at followup, including 14 (46.6%) with full-thickness cartilage loss. Radiographs revealed patellofemoral osteoarthritis in five patients in the Roux-Goldthwait group and in none of the patients in the adductor magnus group. Adductor magnus tenodesis is a reliable method to treat recurrent patellar dislocation. The medial patellofemoral ligament reconstruction seems to reduce the risk of osteoarthrosis compared with distal realignment surgery. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Incidence and risk factors of acute traumatic primary patellar dislocation.

PURPOSE: The purpose of this study was to investigate incidence, nature, and risk factors of primary traumatic patellar dislocations. METHODS: We identified acute first-time traumatic patellar dislocations from a national hospital discharge register. Patients with previous patellar dislocations, subluxations, or knee traumas were excluded. The sample consisted of 128,714 Finnish male conscripts (median age 20). Background risk factor data were obtained from a Finnish conscript service database. The dislocators were observed during their service period for a short-term outcome. RESULTS: From the 128,714 male conscripts, 278 had patellar dislocations, and 72 were classified as having sustained first-time traumatic patellar dislocations. The 128,436 nondislocators served as a control group. The incidence of acute traumatic primary patellar dislocations among male conscripts was 77.4 (95% CI: 61.1-96.8) per 100,000 persons per year. The male patients with traumatic primary patellar dislocations were taller (P = 0.03) and weighed more (P = 0.02) than the controls. Hemarthrosis was present in all patients, and when MRI or open surgery was performed, medial retinacular disruption and medial patellofemoral ligament (MPFL) injury were identified. Patients' return to military service was unrelated to the choice of treatment. CONCLUSION: Primary patellar dislocation is not a negligible cause of morbidity among young male adults. It can be concluded that hemarthrosis and MPFL rupture are the definite signs of an acute traumatic primary patellar dislocation. Height and weight were significant risk factors, whereas poor physical performance was not associated with primary patellar dislocation.

Displaced femoral neck fatigue fractures in military recruits.

BACKGROUND: Displaced fatigue fractures of the femoral neck are uncommon, but they can lead to substantial patient morbidity. This study was performed to examine the incidence, long-term consequences, radiographic findings, risk factors, and complications associated with this fracture. METHODS: Between 1975 and 1994, twenty-one military recruits sustained a displaced fatigue fracture of the femoral neck. Nineteen patients were followed for an average of eighteen years. Data regarding the population at risk, hospital records, initial and follow-up radiographs, and physical findings were analyzed. The impact of instructions from the Finnish Defense Forces, Department of Medical Services, provided in 1986 for prevention of femoral neck fatigue fractures was assessed. RESULTS: At our institution, the incidence of displaced fatigue fractures of the femoral neck was 5.3/100,000 service years from 1975 to 1986, prior to the introduction of the prevention regimen in 1986, and it was 2.3/100,000 service years (95% confidence interval, 0.11 to 1.31) from 1987 to 1994. The rate of Garden type-IV fractures decreased from 3.8 to 0/100,000 service years (95% confidence interval, 0 to 0.66) between the first and second time-periods. The detection of nondisplaced symptomatic fatigue fractures of the femoral neck increased from 15.5 to 53.2/100,000 service years (95% confidence interval, 2.27 to 5.21) between the two time-periods. Eighteen of the nineteen patients had had prodromal symptoms prior to the fracture displacement. Following fracture treatment, six patients had delayed union or nonunion of the fracture. Osteonecrosis of the femoral head developed in six patients and was significantly associated (p = 0.001) with shortening of the femoral neck. Severe osteoarthritis developed in eight patients. CONCLUSIONS: A displaced fatigue fracture of the femoral neck leads to long-term morbidity in a high percentage of patients. Most patients have prodromal symptoms, which provide an opportunity to prevent fracture displacement. Our results indicate that, in a military setting, an educational program can diminish the incidence of fatigue fracture displacement by increasing the awareness of these fractures and their prodromal symptoms and by facilitating diagnosis in the early stages before displacement occurs. LEVEL OF EVIDENCE: Therapeutic Level III.

Malignant tumors at the site of total hip prosthesis. Analytic review of 46 cases.

During the years 1974 to 2003, a total of 46 cases of malignant tumors at the site of total hip arthroplasty, 41 sarcomas, 4 lymphomas, and 1 epidermoid carcinoma, have been reported in the Western literature. Soft tissue sarcomas occurred in 31 and bone sarcomas in 10 cases. Malignant fibrous histiocytoma was the most common in 20 (65%) of all soft tissue sarcomas. The patients with malignant tumors had been operated on more often for secondary osteoarthritis and had more local complications than those in ordinary total hip arthroplasty series. Primary osteoarthritis was the indication in 63% and secondary osteoarthritis in 37% of the 38 reported cases. Tumor developed after 8 (17%) revisions. Deep infection complicated 4 (9%) of the cases. Four cases (9%) were preceded by a precondition for cancer, 2 postradiation necroses of the femoral head, 1 chronic sinus, and 1 Mafucci syndrome. Mean age of the patients at the time of first implantation was 59 years (range, 24-79 years). The mean latent period was 6 years (range, 0.5-20 years) from the first operation. Longer latency period did not correlate positively with the cancer risk. Sarcomas were highly aggressive. Of the 31 reported patients, 24 (77%) died within 1 year after the diagnosis. The number of reported sarcoma cases is low considering the total population behind the cases. In addition, one observed local sarcoma from Nordic cohorts was less than expected. Chronic, particle-induced inflammation around the prosthesis does not seem to increase the risk for carcinogenesis.