Three week versus six week immobilisation for stable Weber B type ankle fractures : randomised, multicentre, non-inferiority clinical trial

OBJECTIVE To determine whether treatment of isolated stable Weber B type ankle fractures with a cast or a simple orthotic device for three weeks produces non-inferior outcomes compared with conventional immobilisation in a cast for six weeks. DESIGN Randomised, pragmatic, non-inferiority, clinical trial with blinded outcome assessment. SETTING Two major trauma centres in Finland, 22 December 2012 to 6 June 2016. PARTICIPANTS 247 skeletally mature patients aged 16 years or older with an isolated Weber B type fibula fracture and congruent ankle mortise in static ankle radiographs. INTERVENTIONS Participants were randomly allocated to conventional six week cast immobilisation (n=84) or three week treatment either in a cast (n=83) or in a simple orthosis (n=80). MAIN OUTCOME MEASURES The primary, non-inferiority, intention-to-treat outcome was the Olerud-Molander Ankle Score at 12 months (OMAS; range 0-100; higher scores indicate better outcomes and fewer symptoms). The predefined non-inferiority margin for the primary outcome was -8.8 points. Secondary outcomes were ankle function, pain, quality of life, ankle motion, and radiographic outcome. Follow-up assessments were performed at 6, 12, and 52 weeks. RESULTS 212 of 247 randomised participants (86%) completed the study. At 52 weeks, the mean OMAS was 87.6 (SD 18.3) in the six week cast group, 91.7 (SD 12.9) in the three week cast group, and 89.8 (SD 18.4) in the three week orthosis group. The between group difference at 52 weeks for the three week cast versus six week cast was 3.6 points (95% confidence interval -1.9 to 9.1, P=0.20), and for the three week orthosis versus six week cast was 1.7 points (-4.0 to 7.3, P=0.56). In both comparisons, the confidence intervals did not include the predefined inferiority margin of -8.8 points. The only statistically significant between group differences observed in the secondary outcomes and harms in the two primary comparisons were slight improvement in ankle plantar flexion and incidence of deep vein thrombosis, both in the three week orthosis group versus six week cast group. CONCLUSION Immobilisation for three weeks with a cast or orthosis was non-inferior to conventional cast immobilisation for six weeks in the treatment of an isolated stable Weber B type fracture.Peer reviewe

Three week versus six week immobilisation for stable Weber B type ankle fractures : randomised, multicentre, non-inferiority clinical trial

OBJECTIVE To determine whether treatment of isolated stable Weber B type ankle fractures with a cast or a simple orthotic device for three weeks produces non-inferior outcomes compared with conventional immobilisation in a cast for six weeks. DESIGN Randomised, pragmatic, non-inferiority, clinical trial with blinded outcome assessment. SETTING Two major trauma centres in Finland, 22 December 2012 to 6 June 2016. PARTICIPANTS 247 skeletally mature patients aged 16 years or older with an isolated Weber B type fibula fracture and congruent ankle mortise in static ankle radiographs. INTERVENTIONS Participants were randomly allocated to conventional six week cast immobilisation (n=84) or three week treatment either in a cast (n=83) or in a simple orthosis (n=80). MAIN OUTCOME MEASURES The primary, non-inferiority, intention-to-treat outcome was the Olerud-Molander Ankle Score at 12 months (OMAS; range 0-100; higher scores indicate better outcomes and fewer symptoms). The predefined non-inferiority margin for the primary outcome was -8.8 points. Secondary outcomes were ankle function, pain, quality of life, ankle motion, and radiographic outcome. Follow-up assessments were performed at 6, 12, and 52 weeks. RESULTS 212 of 247 randomised participants (86%) completed the study. At 52 weeks, the mean OMAS was 87.6 (SD 18.3) in the six week cast group, 91.7 (SD 12.9) in the three week cast group, and 89.8 (SD 18.4) in the three week orthosis group. The between group difference at 52 weeks for the three week cast versus six week cast was 3.6 points (95% confidence interval -1.9 to 9.1, P=0.20), and for the three week orthosis versus six week cast was 1.7 points (-4.0 to 7.3, P=0.56). In both comparisons, the confidence intervals did not include the predefined inferiority margin of -8.8 points. The only statistically significant between group differences observed in the secondary outcomes and harms in the two primary comparisons were slight improvement in ankle plantar flexion and incidence of deep vein thrombosis, both in the three week orthosis group versus six week cast group. CONCLUSION Immobilisation for three weeks with a cast or orthosis was non-inferior to conventional cast immobilisation for six weeks in the treatment of an isolated stable Weber B type fracture.Peer reviewe

Allochthony, fatty acid and mercury trends in muscle of Eurasian perch (Perca fluviatilis) along boreal environmental gradients

Environmental change, including joint effects of increasing dissolved organic carbon (DOC) and total phosphorus (TP) in boreal northern lakes may affect food web energy sources and the biochemical composition of organisms. These environmental stressors are enhanced by anthropogenic land-use and can decrease the quality of polyunsaturated fatty acids (PUFAs) in seston and zooplankton, and therefore, possibly cascading up to fish. In contrast, the content of mercury in fish increases with lake browning potentially amplified by intensive forestry practises. However, there is little evidence on how these environmental stressors simultaneously impact beneficial omega-3 fatty acid (n3-FA) and total mercury (THg) content of fish muscle for human consumption. A space-for-time substitution study was conducted to assess whether environmental stressors affect Eurasian perch (Perea fluviatilis) allochthony and muscle nutritional quality [PUPA, THg, and their derivative, the hazard quotient (HQ)]. Perch samples were collected from 31 Finnish lakes along pronounced lake size (0.03-107.5 km(2)), DOC (5.0-24.3 mg L-1), TP (5-118 mu g L-1) and land-use gradients (forest: 50.7-96.4%, agriculture: 0-32A%). These environmental gradients were combined using principal component analysis (PCA). Allochthony for individual perch was modelled using source and consumer delta H-2 values. Perch allochthony increased with decreasing lake pH and increasing forest coverage (PC1), but no correlation between lake DOC and perch allochthony was found. Perch muscle THg and omega-6 fatty acid (n6-FA) content increased with PC1 parallel with allochthony. Perch muscle DHA (22:6n3) content decreased, and ALA (18:3n3) increased towards shallower murkier lakes (PC2). Perch allochthony was positively correlated with muscle THg and n6-FA content, but did not correlate with n3-FA content. Hence, the quality of perch muscle for human consumption decreases (increase in HQ) with increasing forest coverage and decreasing pH, potentially mediated by increasing fish allochthony.Peer reviewe

Circulating Tumor DNA in Head and Neck Squamous Cell Carcinoma : Association with Metabolic Tumor Burden Determined with FDG-PET/CT

Background: The detection of circulating tumor DNA (ctDNA) with next-generation sequencing (NGS) in venous blood is a promising tool for the genomic profiling of head and neck squamous cell carcinoma (HNSCC). The association between ctDNA findings and metabolic tumor burden detected with FDG-PET/CT imaging is of particular interest for developing prognostic and predictive algorithms in HNSCC. Methods: Twenty-six prospectively enrolled HNSCC patients were eligible for further analysis. All patients underwent tumor tissue and venous liquid biopsy sampling and FDG-PET/CT before definitive oncologic treatment. An NGS-based commercial panel was used for a genomic analysis of the samples. Results: Maximum variant allele frequency (VAF) in blood correlated positively with whole-body (WB) metabolic tumor volume (MTV) and total lesion glycolysis (TLG) (r = 0.510, p = 0.008 and r = 0.584, p = 0.002, respectively). A positive liquid biopsy was associated with high WB-TLG using VAF ≥ 1.00% or ≥5.00% as a cut-off value (p = 0.006 or p = 0.003, respectively). Additionally, ctDNA detection was associated with WB-TLG when only concordant variants detected in both ctDNA and tissue samples were considered. Conclusions: A high metabolic tumor burden based on FDG imaging is associated with a positive liquid biopsy and high maximum VAF. Our findings suggest a complementary role of metabolic and genomic signatures in the pre-treatment evaluation of HNSCC.Peer reviewe

Anatomy of the proximal femoral medullary canal and fit and fill characteristics of cementless endoprosthetic stems

Lonkan tekonivelleikkauksen tavallisin indikaatio on kipua ja liikerajoitusta aiheuttava nivelrikko, artroosi. Tekonivelen reisiosa implantoidaan reisiluun yläosan ydinonteloon ja ns. sementitöntä kiinnitystä käytettäessä luu kasvaa kiinni metallisen implantin huokoiseen pintaan. Väitöskirjassa tutkittiin kadaverireisiluita käyttäen ydinontelon yläosan muodon vaihtelua ja sitä, kuinka erilaiset reisiosat sopivat ydinonteloon sekä kliinisessä sarjassa sitä, kuinka sopivuus vaikuttaa kliinisiin tuloksiin ja luun mukautumiseen viiden vuoden seurannassa. Ensimmäisessä osatyössä kehitettiin rajantunnistusmenetelmiä käyttävä tietokoneohjelma, jolla reisiluun tietokonetomografiakuvauksen poikkileikkeistä pystytään analysoimaan ydinontelon muoto ja dimensiot. Menetelmä testattiin vertaamalla poikkisahattujen reisiluiden ydinontelosta manuaalisesti tehtyjä mittauksia rajantunnistusmenetelmän antamiin tuloksiin. Näiden mittausmenetelmien välinen ero oli keskimäärin 1.1 mm (SD 0.7 mm). Tulosta voidaan pitää hyvänä ja hyväksyttävänä menetelmän käyttämiseksi ydinontelon anatomian tutkimiseen. Toisessa osatyössä 50 reisiluun tietokonetomografiakuvista analysoitiin ydinontelon yläosan anatomiaa tekonivelsuunnittelun ja valinnan kannalta. Uutena havaintona oli, että muodon suuri vaihtelu tapahtuu pääosin aivan reisiluun yläosassa, jossa nimenomaan toivotaan sementittömän tekonivelkomponentin tiivistä kontaktia luuhun ja sen myötä luun kasvua kiinni implanttiin. Ydinontelon yläosan aukeamaa kuvaamaan luotiin uudet indeksit, joiden käyttö helpottaa sopivimman komponentin valintaa kullekin potilaalle. Kolmannessa osatyössä implantoitiin muovista valmistettuja sementittömän lonkkatekonivelen reisiosien kopioita kadaverireisiluihin. Perinteinen röntgenkuvaus antoi implantin täyttöasteesta ydinontelossa 1.2 ­ 1.6 kertaa liian suuria arvoja verrattaessa sitä tietokonetomografiaan yhdistettyyn kuvankäsittelymenetelmään, jota voidaan pitää luotettavana menetelmänä. Kuitenkin korrelaatio näiden mittausmenetelmien välillä oli hyvä (0.76 ­ 0.80). Johtopäätöksenä oli, että perinteistä röntgenkuvausta voidaan käyttää tutkimussarjoissa, joissa erilaisten reisikomponenttien sopivuutta ydinonteloon verrataan keskenään. Neljännessä osatyössä verrattiin kahden designiltaan erilaisen lonkkatekonivelen reisiosan sopivuutta ydinonteloon tekonivelpotilaiden leikkauksen jälkeisistä röntgenkuvista, sekä näillä potilailla todettuja luun mukautumismuutoksia viiden vuoden seurannassa. Kliiniset tulokset molemmissa ryhmissä olivat erinomaiset eikä sopivuus vaikuttanut siihen. Sen sijaan luun mukautuminen tekonivelen aiheuttamiin kuormitusmuutoksiin oli jossain määrin suotuisampaa anatomisesti suunnitelluilla komponenteilla kuin suoravartisilla komponenteilla. Anatomisella tekonivelvarrella luun mukautuminen ei kuitenkaan ollut niin suotuisaa kuin aiemmissa tutkimuksissa on esitetty.Computed tomography (CT) was performed on 50 cadaver femora and an image processing program was developed to analyse the CT data. Ten femora were used for accuracy testing in Study I. The anatomy of the canal of 50 femora was examined in Study II. In Study III 20 cadaver femora were used; plastic replicas of the cementless femoral stem were implanted and the canal fill of the stems measured from standard radiographs and by CT method. The accuracy of radiographs was evaluated and at the same time two different stem designs were compared. In Study IV two patient groups were analysed five years after cementless hip arthroplasty. The first group consisted of 50 patients with Bi-Metric stems (straight, proximal porous coating) and the second of 26 patients with ABG stems (anatomic, proximal HA coating, distal canal overreaming). The fit and fill were measured from immediate postoperative radiographs, bone ingrowth and remodeling was evaluated from 5-year postoperative radiographs and the clinical result was recorded with the Harris hip score. The stem groups were compared, and the influence of the fit and fill on bone remodeling and clinical result was assessed. During the development stage of the image-processing method it became obvious that individual threshold value computation for each image is necessary. There was a mean difference of 1.1 mm (± 0.7 mm) in measured femoral canal diameters between the CT-based image processing system and manual measurement with a caliper ruler. This accuracy was considered acceptable for studying canal anatomy. Also custom?made prostheses could be produced with the three?dimensional data obtained on the femoral canal. The femoral canal opening from isthmus to neck-osteotomy level has been described by the canal flare index (CFI). The average CFI was larger (4.2) and the proportion of wide champagne-fluted canals greater (24%) in this material compared to previous observations. The greatest variation in canal shape was observed in the metaphysis. The metaphyseal canal flare indices (MCFI) were determined to describe the shape of the metaphyseal canal, which should be considered in selecting a suitable femoral stem for an individual patient together with the MCFI variation in designing cementless stems. A dense trabeculation in the calcar region modified the posteromedial canal shape in nearly all femora. This structure is obviously an important support against torsional motion of a femoral stem. The fill values measured from conventional radiographs were excessive, 1.2 ­ 1.6 times higher than actual. However, the correlations between the values from CT and from radiographs were high (r = 0.76 ­ 0.80) if both radiographic views were used, which justifies using radiographic methods for example in clinical studies comparing different stem designs and when the effect of the canal fill on bone remodeling changes is to be assessed. The anatomic design of the ABG yielded significantly higher fill values than the straight Bi-Metric in the metaphysis; this was established in the clinical (78% v. 74%, p Fit and fill had no influence on the clinical results, but the fit and fill characteristics of the stem designs studied were different, as were the consequent bone remodeling changes. In the Bi-Metric group (a straight second-generation stem) there were signs of bone remodeling indicating to distal stress transfer in about half of the cases. In the ABG group (a HA-coated anatomic third-generation stem) slightly more signs of metaphyseal stress transfer were observed than in the straight stem group, but the prevalence was markedly lower than reported in previous studies. Tight diaphyseal fit and fill were clearly related to cortical hypertrophy of the diaphysis. Resorptive changes in the metaphysis appeared independently of metaphyseal fill, but metaphyseal hypertrophy was related to greater metaphyseal fill

Anatomy of the proximal femoral medullary canal and fit and fill characteristics of cementless endoprosthetic stems

Lonkan tekonivelleikkauksen tavallisin indikaatio on kipua ja liikerajoitusta aiheuttava nivelrikko, artroosi. Tekonivelen reisiosa implantoidaan reisiluun yläosan ydinonteloon ja ns. sementitöntä kiinnitystä käytettäessä luu kasvaa kiinni metallisen implantin huokoiseen pintaan. Väitöskirjassa tutkittiin kadaverireisiluita käyttäen ydinontelon yläosan muodon vaihtelua ja sitä, kuinka erilaiset reisiosat sopivat ydinonteloon sekä kliinisessä sarjassa sitä, kuinka sopivuus vaikuttaa kliinisiin tuloksiin ja luun mukautumiseen viiden vuoden seurannassa. Ensimmäisessä osatyössä kehitettiin rajantunnistusmenetelmiä käyttävä tietokoneohjelma, jolla reisiluun tietokonetomografiakuvauksen poikkileikkeistä pystytään analysoimaan ydinontelon muoto ja dimensiot. Menetelmä testattiin vertaamalla poikkisahattujen reisiluiden ydinontelosta manuaalisesti tehtyjä mittauksia rajantunnistusmenetelmän antamiin tuloksiin. Näiden mittausmenetelmien välinen ero oli keskimäärin 1.1 mm (SD 0.7 mm). Tulosta voidaan pitää hyvänä ja hyväksyttävänä menetelmän käyttämiseksi ydinontelon anatomian tutkimiseen. Toisessa osatyössä 50 reisiluun tietokonetomografiakuvista analysoitiin ydinontelon yläosan anatomiaa tekonivelsuunnittelun ja valinnan kannalta. Uutena havaintona oli, että muodon suuri vaihtelu tapahtuu pääosin aivan reisiluun yläosassa, jossa nimenomaan toivotaan sementittömän tekonivelkomponentin tiivistä kontaktia luuhun ja sen myötä luun kasvua kiinni implanttiin. Ydinontelon yläosan aukeamaa kuvaamaan luotiin uudet indeksit, joiden käyttö helpottaa sopivimman komponentin valintaa kullekin potilaalle. Kolmannessa osatyössä implantoitiin muovista valmistettuja sementittömän lonkkatekonivelen reisiosien kopioita kadaverireisiluihin. Perinteinen röntgenkuvaus antoi implantin täyttöasteesta ydinontelossa 1.2 ­ 1.6 kertaa liian suuria arvoja verrattaessa sitä tietokonetomografiaan yhdistettyyn kuvankäsittelymenetelmään, jota voidaan pitää luotettavana menetelmänä. Kuitenkin korrelaatio näiden mittausmenetelmien välillä oli hyvä (0.76 ­ 0.80). Johtopäätöksenä oli, että perinteistä röntgenkuvausta voidaan käyttää tutkimussarjoissa, joissa erilaisten reisikomponenttien sopivuutta ydinonteloon verrataan keskenään. Neljännessä osatyössä verrattiin kahden designiltaan erilaisen lonkkatekonivelen reisiosan sopivuutta ydinonteloon tekonivelpotilaiden leikkauksen jälkeisistä röntgenkuvista, sekä näillä potilailla todettuja luun mukautumismuutoksia viiden vuoden seurannassa. Kliiniset tulokset molemmissa ryhmissä olivat erinomaiset eikä sopivuus vaikuttanut siihen. Sen sijaan luun mukautuminen tekonivelen aiheuttamiin kuormitusmuutoksiin oli jossain määrin suotuisampaa anatomisesti suunnitelluilla komponenteilla kuin suoravartisilla komponenteilla. Anatomisella tekonivelvarrella luun mukautuminen ei kuitenkaan ollut niin suotuisaa kuin aiemmissa tutkimuksissa on esitetty.Computed tomography (CT) was performed on 50 cadaver femora and an image processing program was developed to analyse the CT data. Ten femora were used for accuracy testing in Study I. The anatomy of the canal of 50 femora was examined in Study II. In Study III 20 cadaver femora were used; plastic replicas of the cementless femoral stem were implanted and the canal fill of the stems measured from standard radiographs and by CT method. The accuracy of radiographs was evaluated and at the same time two different stem designs were compared. In Study IV two patient groups were analysed five years after cementless hip arthroplasty. The first group consisted of 50 patients with Bi-Metric stems (straight, proximal porous coating) and the second of 26 patients with ABG stems (anatomic, proximal HA coating, distal canal overreaming). The fit and fill were measured from immediate postoperative radiographs, bone ingrowth and remodeling was evaluated from 5-year postoperative radiographs and the clinical result was recorded with the Harris hip score. The stem groups were compared, and the influence of the fit and fill on bone remodeling and clinical result was assessed. During the development stage of the image-processing method it became obvious that individual threshold value computation for each image is necessary. There was a mean difference of 1.1 mm (± 0.7 mm) in measured femoral canal diameters between the CT-based image processing system and manual measurement with a caliper ruler. This accuracy was considered acceptable for studying canal anatomy. Also custom?made prostheses could be produced with the three?dimensional data obtained on the femoral canal. The femoral canal opening from isthmus to neck-osteotomy level has been described by the canal flare index (CFI). The average CFI was larger (4.2) and the proportion of wide champagne-fluted canals greater (24%) in this material compared to previous observations. The greatest variation in canal shape was observed in the metaphysis. The metaphyseal canal flare indices (MCFI) were determined to describe the shape of the metaphyseal canal, which should be considered in selecting a suitable femoral stem for an individual patient together with the MCFI variation in designing cementless stems. A dense trabeculation in the calcar region modified the posteromedial canal shape in nearly all femora. This structure is obviously an important support against torsional motion of a femoral stem. The fill values measured from conventional radiographs were excessive, 1.2 ­ 1.6 times higher than actual. However, the correlations between the values from CT and from radiographs were high (r = 0.76 ­ 0.80) if both radiographic views were used, which justifies using radiographic methods for example in clinical studies comparing different stem designs and when the effect of the canal fill on bone remodeling changes is to be assessed. The anatomic design of the ABG yielded significantly higher fill values than the straight Bi-Metric in the metaphysis; this was established in the clinical (78% v. 74%, p Fit and fill had no influence on the clinical results, but the fit and fill characteristics of the stem designs studied were different, as were the consequent bone remodeling changes. In the Bi-Metric group (a straight second-generation stem) there were signs of bone remodeling indicating to distal stress transfer in about half of the cases. In the ABG group (a HA-coated anatomic third-generation stem) slightly more signs of metaphyseal stress transfer were observed than in the straight stem group, but the prevalence was markedly lower than reported in previous studies. Tight diaphyseal fit and fill were clearly related to cortical hypertrophy of the diaphysis. Resorptive changes in the metaphysis appeared independently of metaphyseal fill, but metaphyseal hypertrophy was related to greater metaphyseal fill

Lonkan primaariartroplastiat Lordin totaaliendoproteesilla Tayks:ssa 1984-1988

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Nonoperative, open reduction and internal fixation or primary arthrodesis in the treatment of Lisfranc injuries: a prospective, randomized, multicenter trial – study protocol

Abstract Background Lisfranc injuries are known to be rare and often overlooked injuries that can cause long-term disability and pain when missed or treated incorrectly. The wide variety of Lisfranc injuries ranges from subtle ligament distensions to open fracture dislocations. The treatment of Lisfranc joint injuries is still controversial and very little is known about what types of injury can be treated nonoperatively. The current literature provides only two randomized studies on dislocated Lisfranc injuries. These studies have shown that primary arthrodesis (PA) leads to a similar or better outcome and results in fewer secondary operations when compared with open reduction and internal fixation (ORIF) in ligamentous injuries. There have been no previous randomized studies of the nonoperative versus operative treatment of Lisfranc injuries. Therefore, the purpose of this study is to compare the operative and nonoperative treatment of non-dislocated Lisfranc injuries and to compare the ORIF and PA treatment of dislocated Lisfranc injuries. Methods This study is a prospective, randomized, national multi-center trial. The trial comprises two strata: Stratum I compares cast-immobilization versus open reduction and internal fixation (ORIF) treatment of non-dislocated Lisfranc joint injuries. Stratum II compares PA versus ORIF in the treatment of dislocated injuries of the Lisfranc joint. The main hypothesis of stratum I is that the nonoperative treatment of non-dislocated Lisfranc injuries achieves a similar outcome compared with operative treatment (ORIF). The hypothesis of stratum II is that PA of dislocated Lisfranc injuries yields a similar functional outcome compared with ORIF, but that PA results in fewer secondary operations than ORIF. The main outcome measure is the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot score and the secondary outcome measures are Visual-Analogue-Scale Foot and Ankle (VAS-FA), Visual-Analogue-Scale (VAS), rate of secondary operations and other treatment-related complications. The results will be analyzed after the 2-year follow-up period. Discussion This publication presents a prospective, randomized, national multi-center trial study protocol. It provides details of patient flow, randomization, aftercare and methods of analysis of the material and ways to present and publish the results. Trial registration ClinicalTrials.gov identifier: NCT02953067 24.10.2016

Treatment of Acute Achilles Tendon Rupture with a Standardized Protocol in Normal Clinical Setting

Category: Trauma Introduction/Purpose: Achilles tendon rupture (ATR) is a common trauma among active people. Recent high-quality randomized studies, have shown that using a standardized treatment protocol with early weight-bearing and controlled early range-of-motion exercises provides similar clinical outcome than operative treatment without surgery-related complications. The purpose of this study was to find out whether the clinical results and complication rates of standardized treatment protocol in normal clinical setting with non-selected population correspond to those achieved in RCT studies. Methods: A treatment protocol modified from RCT studies of acute ATR was implemented in standard clinical care of Tampere University Hospital in 2008. Both conservative protocol and postoperative care protocol were based on early weight bearing and early range-of motion exercises. All patients treated due to acute ATR in our hospital during 2008 – 2014 (n=514) were included in the study. The patient records were retrospectively evaluated. Results: 514 acute ATRs were treated. 407 (79.2%) of the patients were men and 107 (20,8%) women. The mean age of all patients was 47.2 years. In female patients the mean age was 47.0 years, in males 47.9 years. 239 (46%) of the ATRs were treated operatively and 275 (54%) non-operatively. The proportion of operatively treated patients declined from 70% (2008) to 21% (2014). The mean age of patients in the operative group was 39.7 years and 53.7 years in the non-operative group. The rerupture rate was 4.6% in operative and 5.8% in the non-operative group. 10,4% of patients in operative group had wound problems. Unsatisfactory clinical outcome was reported in 5,0% of the patients in the operative group and in 6,9% of the non-operative group. Conclusion: Our results show that the treatment of acute ATR in our clinic has changed remarkably during the years 2008 to 2014. In 2008 70% of acute ATRs were treated operatively whereas in 2014 only 21%. Our study shows that it is possible to implement a similar treatment protocol than used in the controlled study setting as a part of the daily clincal care. The most important finding, however, is that the clinical outcome of the patients seems to be fully comparable to the clinical results achieved in RCT-study settings despite the heterogenity of the treated patients and medical staff