Detecting hip osteoarthritis on clinical CT: a deep learning application based on 2-D summation images derived from CT

We developed and compared deep learning models to detect hip osteoarthritis on clinical CT. The CT-based summation images, CT-AP, that resemble X-ray radiographs can detect radiographic hip osteoarthritis and in the absence of large training data, a reliable deep learning model can be optimized by combining CT-AP and X-ray images.

INTRODUCTION

In this study, we aimed to investigate the applicability of deep learning (DL) to assess radiographic hip osteoarthritis (rHOA) on computed tomography (CT).

METHODS

The study data consisted of 94 abdominopelvic clinical CTs and 5659 hip X-ray images collected from Cohort Hip and Cohort Knee (CHECK). The CT slices were sequentially summed to create radiograph-like 2-D images named CT-AP. X-ray and CT-AP images were classified as rHOA if they had osteoarthritic changes corresponding to Kellgren-Lawrence grade 2 or higher. The study data was split into 55% training, 30% validation, and 15% test sets. A pretrained ResNet18 was optimized for a classification task of rHOA vs. no-rHOA. Five models were trained using (1) X-rays, (2) downsampled X-rays, (3) combination of CT-AP and X-ray images, (4) combination of CT-AP and downsampled X-ray images, and (5) CT-AP images.

RESULTS

Amongst the five models, Model-3 and Model-5 performed best in detecting rHOA from the CT-AP images. Model-3 detected rHOA on the test set of CT-AP images with a balanced accuracy of 82.2% and was able to discriminate rHOA from no-rHOA with an area under the receiver operating characteristic curve (ROC AUC) of 0.93 [0.75-0.99]. Model-5 detected rHOA on the test set at a balanced accuracy of 82.2% and classified rHOA from no-rHOA with an ROC AUC of 0.89 [0.67-0.97].

CONCLUSION

CT-based summation images that resemble radiographs can be used to detect rHOA. In addition, in the absence of large training data, a reliable DL model can be optimized by combining CT-AP and X-ray images.

No Major Differences in Recovery After Hip Fracture Between Home-Dwelling Female and Male Patients

BACKGROUND

Studies comparing recovery of men and women after hip fracture have reported conflicting results, some reporting worse recovery in male patients, while others found no differences between genders.

METHODS

Recovery was compared in 105 male and 433 female patients with hip fractures and in age-matched groups of patients 50 years or older, who were home-dwelling and received similar rehabilitation. Residential status, walking ability, hip pain and activities of daily living function were recorded at admission and 4 and 12 months postoperatively, along with mortality and re-operations.

RESULTS

No differences were observed between men and women 4 and 12 months postoperatively regarding residential status (p = 0.181 vs p = 0.883), mortality rates (p = 0.232 vs p = 0.880) or total activities of daily living scores (p = 0.546 vs p = 0.435). Walking ability was better among male patients prefracture (p < 0.001) and 4 and 12 months after fracture (p < 0.001, p = 0.031, respectively). In age-matched pair analysis, no differences were found regarding mortality, residential status, walking ability, or ADL score. Cox regression analysis identified mortality risk factors as being age, prefracture ADL score, American Society of Anesthesiologists score 4-5 and place of rehabilitation. Sex was not mortality risk factor.

INTERPRETATION

Home-dwelling male and female patients had similar courses of recovery from hip fracture, although there were singular differences in specific activities of daily living functions and postoperative pain. There were no differences in mortality, even when prefracture characteristics were considered. Mortality was higher among older patients and who had high American Society of Anesthesiologists scores and low prefracture activities of daily living scores.

Histomorphometric Analysis of Poly-L/D-Lactide 96/4 Sutures in the Gastrocnemius Tendon of Rabbits

Background

Common Achilles tendon ruptures are not usually fixed by bioabsorbable sutures due to limitations in their strength retention properties. Modern technology has made it possible to develop bioabsorbable sutures with prolonged strength retention.

Aims

To evaluate histologically tissue reactions of poly-L/D-lactide (PLDLA) sutures implanted in Achilles tendon of rabbits.

Material and Methods

Fifteen rabbits were evaluated at 2, 6 and 12 weeks postoperatively, with five rabbits in each follow-up group. PLDLA monofilament sutures were implanted into the medial gastrocnemius tendon. Polyglyconate monofilament sutures with similar diameter (Maxon® 4–0, Cyanamid of Great Britain Ltd., Gosport, UK) were implanted in the contralateral gastrocnemius tendon. The histology was studied in hard-resin embedded samples. The thickness of the formed fibrous tissue capsule was determined histomorphometrically.

Results

PLDLA led to formation of significantly thinner fibrous tissue capsule than Maxon® sutures of the same diameter. Median thickness (PLDLA vs. Maxon®) at two weeks was 5.26 vs. 13.22μm, at six weeks 11.66 vs. 80.97μm, and at 12 weeks 10.63 vs. 17.59μm (p<0.01).

Conclusions

During the 12 week follow-up period, PLDLA sutures implanted intratendineously formed thinner fibrous capsule than Maxon® sutures of the same diameter. The suture materials were not totally absorbed by 12 weeks.

First Tarsometatarsal Joint Derotational Arthrodesis for Flexible Hallux Valgus: Results from Follow-Up of 3-8 Years

PURPOSE

We report 3- to 8-year follow-up results for the first tarsometatarsal joint derotational arthrodesis.

METHODS

A total of 70 patients (88 feet) with symptomatic flexible hallux valgus were operated between 2003 and 2009. In all, 66 patients (94.3%) with 84 (95.5%) feet were enrolled in retrospective analysis; of those, 58 (87.9%) patients with 76 (90.5%) feet were followed for a mean of 5.1 (range: 3.0-8.3) years. Preoperative, 6 week postoperative, and late follow-up weightbearing radiographs were evaluated along with clinical examination and questionnaires.

RESULTS

The mean hallux valgus angle improved 13.4° (95% confidence interval: 11.6-15.1, p < .001) at the latest follow-up, while the mean intermetatarsal angle correction was 4.5° (95% confidence interval: 3.7-5.2, p < .001). There were three (4.0%) nonunions, and seven (9.2%) feet needed reoperation during follow-up.

CONCLUSION

First tarsometatarsal joint derotational arthrodesis is an effective procedure for correcting flexible hallux valgus deformity and provides a satisfactory long-term outcome.

Supraspinatus outlet view in the diagnosis of stages II and III impingement syndrome

Purpose: To compare supraspinatus outlet view (SOV) findings at different stages of the impingement syndrome (IS) with findings in asymptomatic age- and sex-matched controls.

Material and Methods: Pre-operative SOVs were obtained of 37 shoulders of patients scheduled for unilateral open repair of a full-thickness rotator cuff tear (stage III IS) and 74 shoulders of patients scheduled for open (n=46) or arthroscopic (n=28) acromioplasty for tendinitis (stage II IS). Each view of a patient's shoulder was paired with a control view obtained from an age- and sex-matched person with no shoulder problems (n=111).

Results: There were no significant differences in acromial morphology as evaluated on the scale devised by Bigliani et al. or in the tilt, slope or length of the acromion between the study groups and their controls. However, hooked acromion seemed to be more common in the patients. The thickness of the anterior part of the acromion at the tendinitis stage and the acromial angle at the tear stage of IS were the only parameters that showed significant differences between patients and controls.

Conclusion: Variation of the morphology of the acromion as evaluated on a basis of the SOV is associated with IS, but the association is weak and its value in the diagnosis of IS is therefore only as an adjunctive to other diagnostic modalities.

Grading of Radiographic Osteolytic Changes after Silastic Metacarpophalangeal Arthroplasty and a Prospective Trial of Osteolysis Following Use of Swanson and Sutter Prostheses

The purpose of this study was to compare the incidence of radiographic osteolysis following insertion of 89 Swanson and 126 Sutter metacarpophalangeal implants in rheumatoid arthritis patients. The mean follow-up time in the two groups of patients was 57 (40–80) and 55 (36–79) months, respectively. This paper proposes a new method of classifying radiographic osteolysis. The remarkable number of osteolytic changes seen in the bones adjacent to MCP prostheses in this study would suggest that silastic prostheses should only be used when other surgical alternatives cannot be used and that long-term control by radiography be maintained after implantation of silicone prostheses into the MCP joint. In all grades of our classification, osteolysis was more frequent in the Sutter than in the Swanson group in this study, suggesting that use of the Sutter rather than the Swanson implant is questionable.

Costs after hip fracture in independently living patients: a randomised comparison of three rehabilitation modalities

OBJECTIVE

To evaluate costs and cost-effectiveness of physical and geriatric rehabilitation after hip fracture.

DESIGN

Prospective randomised study (mean age 78 years, 105 male, 433 female) in different rehabilitation settings: physically oriented (187 patients), geriatrically oriented (171 patients), and healthcare centre hospital (control, 180 patients).

MAIN MEASURES

At 12 months post-fracture, we collected data regarding days in rehabilitation, post-rehabilitation hospital treatment, other healthcare service use, number of re-operations, taxi use by patient or relative, and help from relatives.

RESULTS

Control rehabilitation (4945,2€) was significantly less expensive than physical (6609.0€, p=0.002) and geriatric rehabilitation (7034.7€ p<0.001). Total institutional care costs (primary treatment, rehabilitation, and post-rehabilitation hospital care) were lower for control (13,438.4€) than geriatric rehabilitation (17,201.7€, p<0.001), but did not differ between control and physical rehabilitation (15659.1€, p=0.055) or between physical and geriatric rehabilitation ( p=0.252). Costs of help from relatives (estimated as 30%, 50% and 100% of a home aid's salary) with physical rehabilitation were lower than control ( p=0.016) but higher than geriatric rehabilitation ( p=0.041). Total hip fracture treatment costs were lower with physical (36,356€, 51,018€) than control rehabilitation (38,018€, 57,031€) at 50% and 100% of salary ( p=0.032, p=0.014, respectively). At one year post-fracture, 15D-score was significantly higher in physical rehabilitation group (0.697) than geriatric rehabilitation group (0.586, p=0.008) and control group (0.594, p=0.009).

CONCLUSIONS

Considering total costs one year after hip fracture the treatment including physical rehabilitation is significantly more cost-effective than routine treatment. This effect could not be seen between routine treatment and treatment including geriatric rehabilitation.

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.

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.

Survivorship of high tibial osteotomy in the treatment of osteoarthritis of the knee

Previous studies from single centres or single-surgeon series report good early and mid-term results for high tibial osteotomy (HTO) in the treatment of osteoarthritis of the knee. However, the survivorship of HTO at a national level is unknown. This registry-based study included 3195 high HTOs performed between 1987 and 2008. Kaplan-Meier analysis revealed an overall survivorship of 89% (95% confidence interval (CI) 88 to 90) at five years and 73% (95% CI 72 to 75) at ten years, when conversion to total knee replacement was taken as the endpoint. Females and patients aged > 50 years had worse survivorship than males or patients aged ≤ 50 years (hazard ratio (HR) 1.26 (95% CI 1.11 to 1.43) and HR 1.41 (95% CI 1.23 to 1.64), respectively). The survivorship of HTOs performed between 1998 to 2008 was worse than for those performed between 1987 and 1997.

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

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.

Detection of gingival crevicular fluid MMP-8 levels with different laboratory and chair-side methods

OBJECTIVE

The aim of the study was to compare four methods for gingival crevicular fluid (GCF) matrix metalloproteinase (MMP)-8 detection.

METHODS

Matrix metalloproteinase-8 levels from 20 GCF samples from two periodontally healthy subjects, 18 samples from two patients with gingivitis and 45 samples from six patients with moderate to severe periodontitis, altogether 83 samples, were analysed using (1) a time-resolved immunofluorometric assay (IFMA), (2) an MMP-8 specific chair-side dip-stick test, (3) a dentoAnalyzer device and (4) the Amersham ELISA kit. Western immunoblot using same monoclonal anti-MMP-8 as in IFMA and dentoAnalyzer was used to identify molecular forms of MMP-8 in GCFs.

RESULTS

Correlation between IFMA and dentoAnalyzer results calculated with Spearman's correlation coefficient was 0.95 (P = 0.01). The chair-side dip-stick test results were well in line with these assays. Periodontitis sites with unstable characteristics were differentiated with these methods. The Amersham ELISA results were not in line with the findings by other methods.

CONCLUSIONS

Immunofluorometric assay and dentoAnalyzer can detect MMP-8 from GCF samples and these methods are comparable. Using Western immunoblot, it was confirmed that IFMA and dentoAnalyzer can detect activated 55 kDa MMP-8 species especially in periodontitis-affected GCF. dentoAnalyzer is among the first quantitative MMP-8 chair-side testing devices in periodontal and peri-implant diagnostics and research.

Functional comparison of the dynamic hip screw and the Gamma locking nail in trochanteric hip fractures: a matched-pair study of 268 patients

The aim of this prospective matched-pair (age, sex, fracture type, residential status, and walking ability at fracture) study was to analyse the short-term outcome after Gamma nail (GN) and dynamic hip screw (DHS) fixation, focusing especially on functional aspects (Standardised Audit of Hip Fractures in Europe [SAHFE] hip fracture follow-up forms), reoperations, and mortality. Both groups consisted of 134 patients. DHS and GN groups did not differ significantly with respect to location of residence at 4 months or returning to the prefracture dwelling (78% vs. 73%, P = 0.224). The change in walking ability at 4 months compared to prefracture situation was better in the DHS group (p = 0.042), although there was no difference in the change of use of walking aids. The frequency of reoperations during the first year was somewhat lower in the DHS group (8.2% vs. 12.7%, p = 0.318). Mortality was lower in the DHS group both at 4 months (6.0% vs. 13.4%, p = 0.061) and 12 months (14.9% vs. 23.9%, p = 0.044). Although walking ability was better and mortality lower in the DHS group, both methods are useful in the treatment of trochanteric femoral fractures.

Non-constrained titanium-polyethylene total endoprosthesis in the treatment of hallux rigidus. A prospective clinical 2-year follow-up study

BACKGROUND AND AIMS

To evaluate the outcome in a prospective 2-year follow-up study of a non-constrained titanium-polyethylene total endoprosthesis (ReFlexion) in the treatment of hallux rigidus.

MATERIAL AND METHODS

Ten patients with painful hallux rigidus were treated with a non-constrained titanium-polyethylene total endoprosthesis (ReFlexion). The American Orthopaedic Foot and Ankle Society (AOFAS) scoring was used preoperatively and at follow-up.

RESULTS

At 2-year follow-up, the AOFAS scoring shbwed 5 instances of excellent, 1 of good, 2 of fair, and 2 of poor outcome. Eight patient were subjectively satisfied and 2 dissatisfied. Five of the patients were painless, 4 had mild, occasional pain, and 1 had moderate, daily pain in the first metatarsophalangeal joint. The mean VAS was 7.6 (SD 2.0) preoperatively and 1.1 (SD 1.4) at 2-year follow-up (p < 0.001). Extension increased by a mean of 25 (13-38) degrees and flexion by a mean of 15 (2-35) degrees (p < 0.001). Eight patients had no activity limitations, while 1 had mild and 1 moderate limitations. Alignment of the metatarsophalangeal joint was good in 7 cases, but some degree of valgus malalignment was seen in 2 and symptomatic malalignment in 1. Complications included one subluxation of a prosthesis, one recurrence of severe valgus alignment and one superficial wound infection. Radiological loosening of one cementless phalangeal component was seen at follow-up.

CONCLUSION

The non-constrained titanium-polyethylene total arthroplasty gave satisfactory 2-year outcome in 60% of the patients. It is an alternative treatment for hallux rigidus in low demand patients. We do not recommended it for athletes and young people, because high forces acting on the prosthesis may cause a failure.

Acute bilateral exercise-induced medial compartment syndrome of the thigh. Correlation of repeated MRI with clinicopathological findings

We present a case report of acute bilateral excercise-induced compartment syndrome in the adductor longus muscles, which was treated with bilateral medial fasciotomies. Postoperatively, the healing process of the adductor muscles was followed up by repeated MR imagings over six months. Myonecrosis was found in peroperative muscle biopsies. Pain and muscle swelling subsided soon after the fasciotomy, correlating with the early postoperative MR findings. Four months postoperatively, the signal intensity of the adductor muscles was normal in T1- and T2-weighted images, but the normal fibre structure of the adductor muscles could only be seen 6 months postoperatively. At six month's control checkup there was no subjective weakness of the adductors, and hyperesthesia had disappeared and the patient was capable of normal activities.

Arthroscopic repair of osteochondritis dissecans of the femoral condyles with metal staple fixation: a report of 28 cases

In a retrospective clinical study we evaluated the outcome of arthroscopic repair of osteochondritis dissecans (OCD) of the femoral condyles with metal stable fixation. Twenty-eight knees of 26 patients (mean age 20 years) with OCD of the knee were treated by fixation of the fragments with Hoffmann's dynamic metal staples arthroscopically and by additional arthrotomy in 7 knees. At follow-up (mean 4 years, 1-7) patients were interviewed for any residual symptoms and underwent a routine clinical and radiographic examination. The clinical results were based on the grading scale of Lysholm. The 17 knees which did not require further surgery showed 13 instances of complete healing, 3 of partial healing, and 1 of nonhealing. The 11 knees which had reoperations showed 2 instances of complete healing, 5 of partial healing, and 4 nonhealing. There was no significant difference between early or late surgery, and results were not related significantly to site of the lesion, handling of the fragment and the crater, percutaneous drilling, or type of fragmentation. Clinical grading of 13 knees was as excellent, 11 good, and 4 fair. Broken stables were observed in 9 knees, and they were removed from 5 knees. Complete healing was thus achieved in one-half and partial healing in one-third of cases. The metal staples used here fit for use in the arthroscopic fixation of the OCD of the knee, although the staples had a marked liability to break.

Supraspinatus outlet view in the diagnosis of stages II and III impingement syndrome

PURPOSE

To compare supraspinatus outlet view (SOV) findings at different stages of the impingement syndrome (IS) with findings in asymptomatic age- and sex-matched controls.

MATERIAL AND METHODS

Pre-operative SOVs were obtained of 37 shoulders of patients scheduled for unilateral open repair of a full-thickness rotator cuff tear (stage III IS) and 74 shoulders of patients scheduled for open (n=46) or arthroscopic (n=28) acromioplasty for tendinitis (stage II IS). Each view of a patient's shoulder was paired with a control view obtained from an age- and sex-matched person with no shoulder problems (n=111).

RESULTS

There were no significant differences in acromial morphology as evaluated on the scale devised by BIGLIANI et al. or in the tilt, slope or length of the acromion between the study groups and their controls. However, hooked acromion seemed to be more common in the patients. The thickness of the anterior part of the acromion at the tendinitis stage and the acromial angle at the tear stage of IS were the only parameters that showed significant differences between patients and controls.

CONCLUSION

Variation of the morphology of the acromion as evaluated on a basis of the SOV is associated with IS, but the association is weak and its value in the diagnosis of IS is therefore only as an adjunctive to other diagnostic modalities.

Surgical treatment of resistant tennis elbow. A prospective, randomised study comparing decompression of the posterior interosseous nerve and lengthening of the tendon of the extensor carpi radialis brevis muscle

We compared decompression of the posterior interosseous nerve (PIN) and lengthening of the distal tendon of the extensor carpi radialis brevis (ECRB) for treatment of tennis elbow in a randomised trial of 28 patients. Fourteen underwent decompression of PIN and 14, lengthening of ERCB. The groups did not differ significantly with regard to age, sex and work activities. The average duration of preoperative symptoms was 23 months. The PIN was exposed in the groove between the brachioradialis and brachialis muscles and decompressed at the arcade of Frohse by means of a 1-2 cm incision through the supinator muscle. The ECRB tendon was lengthened by Z-plasty at the dorsilateral aspect of the forearm. No postoperative complications occurred. The outcome after the primary operation was successful in 50% of the PIN group and in 43% of the ECRB group. Four of the 5 patients with a poor outcome were reoperated in the former group and 3 in the latter. The overall outcome after a mean follow-up of 31 months after the primary operation was successful in 60% of the cases.

Comparison of strength properties of poly-L/D-lactide (PLDLA) 96/4 and polyglyconate (Maxon) sutures: in vitro, in the subcutis, and in the achilles tendon of rabbits

Achilles tendon rupture is a common injury. Absorbable sutures are not commonly used because of their limited strength properties. Recently, sutures with prolonged strength retention properties have been developed. The aim of the study is to test the mechanical properties of recently developed poly-L/D-lactide (PLDLA) sutures in comparison with polyglyconate (Maxon) sutures. PLDLA (0.2 mm thick) and Maxon (4.0) sutures were studied in vitro by immersion in a buffered saline solution (pH 7.4). Tensile strength tests were done on sutures retrieved after 1-26 weeks. In vivo, they were implanted in the subcutis of 32 rabbits. Tensile strength tests were done on sutures retrieved after 1-6 weeks. The sutures were also used to repair the Achilles tendon in rabbits. Maximum force before breaking and percentage elongation of tendons were determined. Although PLDLA had a lower initial tensile strength than Maxon, PLDLA showed more prolonged tensile strength retention than Maxon. Tendons repaired with PLDLA, however, had a lower strength than Maxon-repaired tendons at six weeks (insignificant difference). PLDLA has more prolonged tensile strength properties compared with Maxon. Thus, PLDLA offers an alternative to Maxon in repair of the Achilles tendon.

Study of straight metatarsal osteotomy for the treatment of plantar callosities

BACKGROUND AND AIMS

[corrected] To evaluate the outcome of transverse distal metatarsal osteotomies for intractable plantar callosity without hammer toe deformity and associated toe corns.

MATERIAL AND METHODS

Twenty-five plantar callosities were treated in 19 feet of 13 patients (mean age 48 years, 5 male, 8 female) with transverse distal metatarsal osteotomy.

RESULTS

Twenty-four of the osteotomies united primarily, one after revision. After a 7-year follow-up, 23 of the callosities had healed, two of them after an oblique reosteotomy. Eight hammer toe deformities had developed in the involved rays of four feet. Eight plantar callosities had developed outside the operated rays in five feet. Hallux valgus was a frequent finding in both operated and non-operated feet.

CONCLUSION

It seems that transverse distal metatarsal osteotomy is an effective treatment of intractable plantar callosities. Harmful hammer toe deformities and transfer lesions below adjacent metatarsal heads tend to develop over time.

Results of surgical treatment of unresolved Osgood-Schlatter lesion

BACKGROUND AND AIMS

We present our experience with surgical treatment of unresolved, painful, late Osgood-Schlatter disease.

MATERIAL AND METHODS

In 70 operations performed in 67 patients (in three bilaterally) an ossicle under the distal patellar tendon was removed in 62 cases. In eight cases, excision of the prominent tibial tubercle and/or drilling of the epiphysis was performed. Additional procedures, such as rasping of the uneven anterior tibial surface, excision of inflammed bursa or the devitalized portion of the tendon, were done 21 times. Most patients were athletes or physically active young people. The mean age was 19.6 years. 54 operations were done on males and 16 on females. They had been followed preoperatively for 18 months and after surgery 2.2 years.

RESULTS

The final results were excellent or good in 56, moderate in 9, poor in 3 and unknown in 2 cases.

CONCLUSIONS

Osgood-Schlatter's disease may leave an ossicle under the distal patellar tendon, a prominent tibial tubercle or an uneven surface of anterior superior tibia. These may lead to pain and disability due to recurrent injuries or athletic exercises. Surgical treatment gives good results in chronic unresolved cases.

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.

Early excision of the radial head for fracture

The wrists and elbows of 23 patients were examined at a mean follow-up of 5 years (2-10 years) after excision of the radial head for an isolated fracture. Fourteen elbows and 13 wrists were symptomatic. Proximal migration of the radius was seen in 15 cases; the mean distance of migration being 1.4 mm. Osteoarthritis, mostly mild, was seen in 17 elbows and 14 wrists and limited movement of the elbow was a common finding. Excision of the radial head for fracture had a high complication rate.

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.

Relationship between calf muscle size and strength after achilles rupture repair

The object was to study the relationships between calf muscle size and strength in 85 patients an average of 3.1 years after repair of achilles tendon rupture. The isokinetic calf muscle strength results were excellent or good for 73% of the patients, whereas calf muscle size was normal in only 30%. The average plantar flexion peak torque per unit muscle cross-sectional area was higher on the injured side than on the uninjured side. The average calf muscle cross-sectional area deficit was 15+/-9% (p<0.001) of that on the unaffected side, while the average plantar flexion peak torque deficit was speed-dependent, being 9+/-18%, 10+/-18 and 2+/-13% of that on the unaffected side at 30, 90, and 240 degrees/sec (p<0.001). The correlation between cross-sectional area and peak torque varied in the range 0.52-0.61 at 30, 90 and 240 degrees/sec (p<0.001).

Chronic Achilles tendon overuse injury: complications after surgical treatment. An analysis of 432 consecutive patients

We analyzed the complications after surgical treatment of Achilles tendon overuse injuries in 432 consecutive patients. The patients underwent a clinical examination 2 weeks, and 1, 2, and 5 months after the surgery. If a complication appeared, the patient was followed up clinically for at least 1 year. There were 46 (11%) complications in the 432 patients: 14 skin edge necroses, 11 superficial wound infections, 5 seroma formations, 5 hematomas, 5 fibrotic reactions or scar formations, 4 sural nerve irritations, 1 new partial rupture, and 1 deep vein thrombosis. Fourteen patients with a complication had reoperations: four patients for skin edge necrosis, two for superficial wound infection, two for seroma formation, one for hematoma formation, two for fibrotic reaction or scar formation, two for sural nerve irritation, and one for a new partial rupture. About every 10th patient treated surgically for chronic Achilles tendon overuse injury suffered from a postoperative complication that clearly delayed recovery. However, the majority of patients with a complication healed and returned to their preinjury levels of activity. To reduce this morbidity, it is essential that the surgeon be continuously aware of the possibility of postoperative complications and use proper surgical techniques.

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.

Ruptures of the Achilles tendon: relationship to inequality in length of legs and to patterns in the foot and ankle

We studied 101 patients who were operated on at Oulu University Hospital for ruptured Achilles tendon from 1987 to 1992 (inclusive), and 87 healthy control patients from among Army conscripts. The mean inequality in length of legs (ILL) was 5 +/- 4 mm. Among the 48 patients with ILL > or = 5 mm, the side affected with ruptured tendon was longer in 48% of cases and shorter in 52%. An underpronating alignment of the ankle and foot (based on beta45 measurement of the angle < or = 4 degrees) was found in 21% of patients and 5% of controls (P < 0.001). A combination of high longitudinal arch and underpronating alignment of the ankle was seen in 10% of patients and 1% of controls (P < 0.001). About 37% of the patients' feet and 29% of feet in controls were classified as having a high arch (P = 0.001). ILL or hyperpronation of the ankle seem to not be predisposing factors for ruptures of the Achilles tendon. High longitudinal arches were somewhat overrepresented, being associated with less pronation of the ankle and less varus in the forefoot than was seen in controls.

Ultrasound and operative evaluation of arthritic shoulder joints

OBJECTIVE

To assess the diagnostic value of ultrasonography (US) in the evaluation of arthritic shoulder joints.

METHODS

Twenty shoulders of 20 inpatients with arthritis were evaluated by US one day before the shoulder operation. Changes in the subacromial-subdeltoid bursa, biceps tendon and tendon sheath, rotatof cuff, and glenohumeral joint were recorded and compared with findings at operation.

RESULTS

In the detection of effusion/hypertrophy in the subacromial-subdeltoid bursa, US had a sensitivity of 93% and a specificity of 83%. For a biceps tendon rupture US had a sensitivity of 70% and a specificity of 100%. US missed three intraarticular biceps tendon ruptures. For effusion/hypertrophy in the biceps tendon sheath US had a sensitivity of 100% and a specificity of 83%. For a rotator cuff tear US had a sensitivity of 83% and a specificity of 57%. US missed two small longitudinal rotator cuff tears. Three thin membranous, but intact, rotator cuff tendons were classified as full thickness tears by US. Synovial effusion/hypertrophy was detected by US and at operation in all of the 12 glenohumeral joints that were evaluable at surgery.

CONCLUSION

US is a reliable method in experienced hands for the evaluation of inflammatory changes of an arthritic shoulder. In advanced stages of rheumatoid shoulder joints, however, US is not useful, because destructive bone changes and tendon ruptures change the normal anatomy and restrict shoulder motions, limiting the visibility of US.

Total Achilles tendon rupture. A review

There are only a few epidemiological studies on the incidence of Achilles tendon (AT) ruptures. These show an increase in incidence in the West during the past few decades. The main reason is probably the increased popularity of recreational sports among middle-aged people. Ball games constitute the cause of over 60% of AT ruptures in many series. The 2 most frequently discussed pathophysiological theories involve chronic degeneration of the tendon and failure of the inhibitory mechanism of the musculotendinous unit. There are reports of AT ruptures related to the use of corticosteroids, either systemically or locally, but the role of corticosteroids in large patient series is marginal. In addition, recent studies do not confirm earlier findings of blood group O dominance in patients with AT rupture. Comparable series have been published with surgical versus nor surgical treatment and postoperative cast immobilisation versus early functional treatment. Although conservative treatment has its own supporters, surgical treatment seems to have been the method of choice in the late 1980s and the 1990s in athletes and young people and in cases of delayed ruptures. Early ruptures in non-athletes can also be treated conservatively. In small series of compliant, well motivated patients, functional postoperative treatment has been reported to be well tolerated, safe and effective. The lack of a universal, consistent protocol for subjective and objective evaluation of AT ruptures has prevented any direct comparison of the results. The results have been often assessed according to the criteria of Lindholm or Percy and Conochie, but no scoring is available for the analysis. We assessed a new scoring method and analysed the prognostic factors related to the results. There is also no single, uniformly accepted surgical technique. Although early ruptures have been treated successfully with simple end-to-end suture, many authors have combined simple tendon suture with plastic procedures of various types. No randomised study comparing simple suture technique and repair with augmentation could be found in the literature. The major complaint against surgical treatment has been the high rate of complications. Most are minor wound complications, which delay improvement but do not influence the final outcome. Major complications are rare, but often difficult to treat with minor procedures. For instance, large postoperative skin and soft tissue defects in the Achilles region can be treated successfully with a microvascular free flap reconstruction. The complications of conservative treatment include mostly reruptures and residual lengthening of the tendon, which may result in significant calf muscle weakness. It has been postulated that a physically inactive lifestyle leads to a decrease in tendon vascularisation, while maintenance of a continuous level of activity counteracts the structural changes within the musculotendinous unit induced by inactivity and aging. Proper warm-up and stretching are essential for preventing musculotendinous injuries, but improper or excessive stretching or warming-up can predispose to these injuries.

Outcome and prognostic factors of achilles rupture repair using a new scoring method

A new clinical scoring system, including subjective assessment of symptoms and evaluation of ankle range of motion and isokinetic measurement of ankle plantar flexion and dorsiflexion strengths, is presented in 101 patients (86 men, 15 women) who had repair of a closed Achilles tendon rupture. Twenty-one patients were competitive athletes and 70 were recreational athletes. Eighty-one percent of the ruptures were related to sports, and 32% occurred while playing volleyball. Twenty-six patients had previous Achilles tendon symptoms. At followup, an average of 3.1 years after repair, the overall result scores were excellent in 34 cases, good in 46, fair in 17, and poor in four. Only age was a predictor of overall results. The isokinetic strength scores were excellent or good in 72 cases, fair in 18, and poor in 11. Presence of systemic diseases, activity level, previous Achilles tendon symptoms, and later return to physical exercise were predictors of strength results. Gender, body weight, height, period between rupture and operation, surgeon, rupture site, operative method, complications, and thickness, width, and area of the Achilles tendon at followup were not related significantly to the outcome.

Isokinetic evaluation of calf muscle performance after Achilles rupture repair

The purposes of this study was 1) to assess the plantar flexion and dorsiflexion peak torques (PT) of the ankles at 30, 90 and 240.. s-1 in 101 patients (86 men, 15 women) who had been operated on for unilateral, complete closed Achilles tendon (AT) rupture at Oulu University Hospital, Oulu, Finland, in the period 1987-1992, 2) to determine whether comparison between the legs shows any impairment, 3) to study whether the weakness is speed-dependent, 4) to determine at what angular displacement of the ankle the weakness is manifested, 5) to study how the results correlate with age, type of operation and follow-up time. The Lido Multi-joint II dynamometer was used for the measurements. There was no significant dorsiflexion weakness detectable upon comparison between the legs, but the mean relative peak torque deficits in the injured limb were 8.4, 9.0 and 3.0% at 30, 90 and 240.. s-1 respectively for the men and 15.0, 16.6 and 6.4% for the women. The mean percentage torque differences were significantly greater in the women at all the test speeds (p < 0.05). The difference in PT was significantly greater at the two low test speeds (30 and 90.. s-1) than at the high speed (240.. s-1, p < 0.001). The weakness was manifested at an angular displacement of 80-120 degrees, where the average peak work (PW) difference between the two legs was significant in both sexes (p < 0.05). The patient's age (21-63), the type of operation (Lindholm or Silfverskiöld technique) and the follow-up time (0.7-6.7 years) did not significantly affect the results. In conclusion, and AT rupture implied an average 3.0 to 16.6% impairment in isokinetic plantar flexion muscle strength. The impairment was greater in the women, was manifested at an angular displacement of 80-120 degrees, and was greater at low test speeds. Age, type of operation and follow-up time did not account for the PT differences between the patients.

Bilateral Achilles tendon rupture: a report on two cases

Two cases of traumatic bilateral Achilles tendon rupture are reported. One of the patients was a healthy middle-aged man, who had been an active national-level gymnast 20 years earlier. He had not suffered any complaints of Achilles tendons before. The ruptures occurred when, after a sauna, he showed his guests a vault forwards, which he had been able to perform easily. This time the landing took place on the toes, causing a high peak stretch to the calf muscles and Achilles tendons. The total rupture of both Achilles tendons was treated surgically, with an excellent result 2 days after the trauma. End-to-end suturation and a fascial flap plasty were made on both sides. No macroscopic degeneration could be detected on the rupture sites. He was allowed to walk freely 6 weeks after the surgery. The second case was a 54-year-old woman, who had suffered from Achilles tendinitis and peritendinitis for 2 years. Both tendons had been surgically treated, and severe adhesions and local degenerative changes had been found. The tendon rupture occurred when she injured her left ankle while getting out of the car. Two days later she fell at home, because of the weakness of the left side, and consequently the right Achilles tendon was injured. She was treated conservatively for 10 days, before the surgery was performed. Both tendons were ruptured and an extensive degeneration of the area was observed. The right side suffered from a rerupture, which was again treated surgically. After surgery the recovery was slow, but the final result 3 years later was moderate. Neither of the patients had any systemic diseases.

Free tissue coverage of wound complications following Achilles tendon rupture surgery

The purpose of this study was to examine the long term functional results following free tissue coverage in 4 patients who developed wound complications after surgical treatment of partial or total Achilles tendon rupture. Between 1987 and 1993, 3 radial forearm flaps and 1 lateral arm flap were used. Two Achilles tendons were reinforced, 1 with palmaris longus tendon, and 1 with extensor carpi radialis and palmaris longus tendons. The patients were seen during followup an average of 3.1 years after the reconstruction. All patients were able to return to their preoperative level of activity within a year, and the aesthetic outcome was good in all cases. Isometric and isokinetic calf muscle performance was evaluated with a Lido Multi Joint II dynamometer, which showed the mean of isometric test values in 3 patients to be greater than 90% of that of the normal unaffected side, and probably abnormal (80%) in 1 patient. The mean isometric values obtained in 3 ankle positions, 20 degrees plantar flexion, neutral, and 10 degrees dorsiflexion, were 114%, 104%, and 94%, respectively. Isokinetic peak torque values were normal in 3 patients at a velocity of 30 degrees per second, and in 2 at 90 degrees per second. The mean peak torque value was 90% of normal at both angle velocities. The cross sectional area of the calf muscle was greater than 90% of the normal unaffected side. Ultrasonography indicated that the diameters of 2 reinforced tendons were larger than those on the control sides. Posterior peritendinous fibrosis was found in the upper corner of the scar in 2 patients.

Incidence of Achilles tendon rupture

We determined the incidence of a total Achilles tendon rupture in the city of Oulu and changes over the 16-year period 1979-1994. During this time, 110 ruptures occurred. The incidence increased from 2 ruptures/10(5) inhabitants in 1979-1986 to 12 in 1987-1994, with a mean of 7. The peak annual incidence, 18, was recorded in 1994. The incidence was highest in the age group 30-39 years. Male dominance was 5.5:1, and 81% of the ruptures were related to sports, with 88% occurring in ball games. The mean age was significantly lower for the sports injuries.

ABO blood group and Achilles tendon rupture

The association between ABO blood groups and Achilles tendon (AT) ruptures was studied in 215 consecutive AT rupture patients treated at Oulu University Hospital during the 16-year period from 1979 to 1994 as compared with control material consisting of earlier blood group determinations performed on an unselected sample of 5,536 young Finnish male adults. There was no blood group O dominance or other statistical differences in ABO blood groups between the patients with AT rupture and the control population (chi 2 3.79, P = 0.28), the A/O ratio being 1.82 in the rupture group and 1.42 in the controls. We found no blood group O dominance in competitive athletes, recreational athletes or non-athletes, in patients with sports-related AT ruptures or non-sports-related ruptures and in younger (< 45 years) or older (> or = 45--years) patients. In conclusion, our results do not confirm early findings of blood group O dominance in patients with AT rupture.

Responses of type I and type III collagen synthesis after replacement of the hip joint

Liberation of the carboxy-terminal propeptide of type I procollagen (PICP) and the amino-terminal propeptide of type III procollagen (PIIINP) into body fluids reflects synthesis of the respective collagen types. Here, we followed PICP and PIIINP in serum with specific radioimmunoassays after hip surgery. Preoperative median of S-PICP was 112 micrograms/liter (range 87 to 154, n = 9), the 1-day median being 58 micrograms/liter (33 to 79). The corresponding medians for S-PIIINP were 4.4 micrograms/liter (3.5 to 7.0) and 3.3 micrograms/liter (2.0 to 3.5). The medians reached their maximums 14 days after surgery, 172 micrograms/liter (122 to 440) for S-PICP and 12.4 micrograms/liter (8.0 to 15.4) for S-PIIINP, after which the preoperative values were slowly approached over several months. Comparable results were found in a greater sample (n = 50). Our results indicate that the synthesis of structural collagen is inhibited immediately after surgery, but the inhibition is soon overcome by active collagen synthesis at the site of trauma. Collagen metabolism remains activated for several months after surgery.