Treatment after traumatic shoulder dislocation: a systematic review with a network meta-analysis

Objective To review and compare treatments (1) after primary traumatic shoulder dislocation aimed at minimising the risk of chronic shoulder instability and (2) for chronic post-traumatic shoulder instability. Design Intervention systematic review with random effects network meta-analysis and direct comparison meta-analyses. Data sources Electronic databases (Ovid MEDLINE, Cochrane Clinical Trials Register, Cochrane Database of Systematic Reviews, Embase, Scopus, CINAHL, Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, DARE, HTA, NHSEED, Web of Science) and reference lists were searched from inception to 15 January 2018. Eligibility criteria for selecting studies Randomised trials comparing any interventions either after a first-time, traumatic shoulder dislocation or chronic post-traumatic shoulder instability, with a shoulder instability, function or quality of life outcome. Results Twenty-two randomised controlled trials were included. There was moderate quality evidence suggesting that labrum repair reduced the risk of future shoulder dislocation (relative risk 0.15; 95% CI 0.03 to 0.8, p=0.026), and that with non-surgical management 47% of patients did not experience shoulder redislocation. Very low to low-quality evidence suggested no benefit of immobilisation in external rotation versus internal rotation. There was low-quality evidence that an open procedure was superior to arthroscopic surgery for preventing shoulder redislocations. Conclusions There was moderate-quality evidence that half of the patients managed with physiotherapy after a first-time traumatic shoulder dislocation did not experience recurrent shoulder dislocations. If chronic instability develops, surgery could be considered. There was no evidence regarding the effectiveness of surgical management for post-traumatic chronic shoulder instability.Peer reviewe

Outcomes in a cohort of 39 geriatric AO/OTA C- type fractures of the distal humerus after open reduction and internal fixation with locking plate constructs

Retrospektiivisen tutkimuksen tavoitteena on selvittää HUS Töölön Sairaalassa vuosina 2007-2016 lukkolevyosteosynteesillä hoidettujen olkaluun alaosan nivelpintaan ulottuvien murtumien (AO-C-tyyppi) lyhyen ja keskipitkän aikavälin toiminnallisia ja radiologisia tuloksia. Samalla saadaan tietoa epätyydyttävää tulosta ennustavista tekijöistä ja voidaan verrata tuloksia kyynärtekonivelaineistoihin. Olkaluun alaosan nivelen sisäinen murtuma johtaa hoitamattomana huonon toimintakyvyn tarjoavaan kyynärpähän. Nuorilla hoitolinja on rutiininomaisesti operatiivinen, avoreduktio ja osteosynteesi kyynärnivelen toiminnan palauttamiseksi. Vanhuksilla osteosynteesi on teknisesti haastavaa murtumien mittavammasta pirstaleisuudesta johtuen sekä murtuman kiinnityksen pettämisiä, luutumattomuutta ja jäykkyyttä ajatellaan esiintyvän enemmän kuin työikäisillä. Kyynärnivelen tekoniveltä on tarjottu ratkaisuksi vanhusten murtumien hoidossa. Töölön sairaalan suuri volyymi tarjoaa myös kansainvälisesti merkittävän kokoisen potilasmateriaalin. Tutkimukseen pyydetään kaikkia 1.1.2007- 30.6.2016 Töölön sairaalassa olkaluun alaosan C-tyypin murtuman vuoksi leikkauksella hoidettuja murtuman syntyhetkellä yli 65-vuotiaita potilaita. Alkuajankohta on valittu siten, että lukkolevyt ovat siihen mennessä vakiinnuttaneet asemansa rutiinihoitona. Soveltuvat potilaat kutsutaan tutkimuskäynnille, jonka yhteydessä yläraajojen toimintakyky tutkitaan kliinisesti sekä vastataan toimintakykymittareiden kysymyksiin. Tutkimuksen päätulosmuuttuja on Oxford Elbox Score (OES) –mittari, joka määrittää kyselylomakkeen avulla kyynärnivelen toimintakyvyn vaikutusta arkielämään. Toissijaisina tulosmuuttujina ovat Mayo Elbow Performance Score (MEPS) –mittari, quick-DASH, kyynärnivelen kliinisesti määritetty toimintakyky ja potilaan subjektiivinen tyytyväisyys kyynärpään toimintaan. Lisäksi otetaan kyynärnivelen rtg-kuvat radiologisten muutosten selvittämiseksi. Potilailta määritetään myös terveen puolen toimintakyky, jolloin kunkin terve puoli toimii vertailuryhmänä. Seuranta-aika tulee olemaan vähintään yksi vuosi vammasta, suurimmillaan noin 8,5 vuotta. Keskeisiä taustatietoja ovat vammamekanismi, murtuman luokka ja vammaan sekä leikkaushoitoon liittyvät komplikaatiot. Tutkimus julkaistaan kyseisen erikoisalan kansainvälisessä lääketieteen lehdessä. Tutkimuksen tuloksia voidaan hyödyntää määrittämään HUS Töölön sairaalassa käytössä olevia hoitolinjoja kyseisen vammatyypin osalta

Kiertäjäkalvosinoireyhtymä - diagnostiikka ja hoitolinjan valinta

English summar

Kiertäjäkalvosinoireyhtymä - etiologia

English summar

Hip prosthesis introduction and early revision risk A nationwide population-based study covering 39,125 operations

Peer reviewe

Overstay and Readmission in Ear, Nose, and Throat Day Surgery—Factors Affecting Postanesthesia Course

Aims:Many procedures in ear, nose, and throat (ENT) day surgery are carried out under local anesthesia in Finland, whereas many other countries use general anesthesia. We investigated overstay and readmission rates in local and general anesthesia at Helsinki University Hospital.Material and Methods:We conducted a retrospective study on ENT (n = 1011) day surgery patients within a 3-month period using the hospital?s surgery database to collect data pertaining to anesthesia, overstays, readmissions, and contacts within 30 days of surgery.Objectives:We examined the effect of American Society of Anesthesiologists (ASA) class, age, sex, type of procedure, and anesthesia type on overstay, contact, and readmission rates.Results:A multivariable logistic regression model included ASA class, age, sex, type of procedure, and anesthesia (local vs general). Sex, age, and type of procedure had an effect on the outcomes of overstay, readmission, or contact. With general anesthesia, 3.2% (n = 23) had an overstay or readmission compared to 1.4% (n = 4) after local anesthesia. This was mainly explained by the number of study outcomes in tonsillar surgery that was performed only in general anesthesia.Conclusions:Day surgery could be done safely using local anesthesia, as the number of study outcomes was no greater than in general anesthesia. Sex, type of procedure, and age affected the rate of study outcomes, but ASA class and anesthesia form did not. Our overstay, contact, and readmission rates are on the same level, or lower, than in international studies.Peer reviewe

Root causes of extended length of stay and unplanned readmissions after orthopedic surgery and hand surgery : a retrospective observational cohort study

Background While previous studies have evaluated the effect of some patient characteristics (e.g. gender, American Society of Anesthesiologists (ASA) class and comorbidity) on outcome in orthopedic and hand day surgery, more detailed information on anesthesia related factors has previously been lacking. Our goal was to investigate the perioperative factors that affect overstay, readmission and contact after day surgery in order to find certain patient profiles more prone to problemed outcomes after day surgery. Methods We examined orthopedic and hand day surgery at an orthopedic day surgery unit of Helsinki University Hospital. Patient data of all adult orthopedic and hand day surgery patients (n = 542) over a 3-month period (January 1 - March 31, 2015) operated on at the unit were collected retrospectively using the hospital's surgery database. These data comprised anesthesia and patient records with a follow-up period of 30 days post-operation. Patients under the age of 16 and patients not eligible for day surgery were excluded. Patient records were searched for an outcome of overstay, readmission or contact with the emergency room or policlinic. Pearson chi-square test, Fischer's exact test and multivariable logistic regression were used to analyze the effect of various perioperative factors on postoperative outcome. Results Various patient and anesthesia related factors were examined for their significance in the outcomes of overstay, readmission or contact. Female gender (p = 0.043), total amount of fentanyl (p = 0.00), use of remifentanil (p = 0.036), other pain medication during procedure (p = 0.005) and administration of antiemetic medication (p = 0.048) emerged as statistically significant on outcome after day surgery. Conclusions Overstay and readmission in orthopedic and hand day surgery were clearly connected with female patients undergoing general anesthesia and needing larger amounts of intraoperative opioids. By favoring local and regional anesthesia, side effects of general anesthesia, as well as recovery time, will decrease.Peer reviewe

Elevated risk of early reoperation in total hip replacement during the stage of unit closure A population-based registry study of total hip and knee replacements in -Finland, 1998-2011

Background and purpose - The effects of launch or closure of an entire arthroplasty unit on the first or last patients treated in these units have not been studied. Using a 3-year follow-up, we investigated whether patients who were treated at the launch or closure stage of an arthroplasty unit of a hospital would have a higher risk of reoperation than patients treated in-between at the same units. Patients and methods - From the Finnish Arthroplasty Register, we identified all the units that had performed total joint arthroplasty and the units that were launched or closed in Finland between 1998 and 2011. The risks of reoperation within 3 years for the 41,748 total hip and knee replacements performed due to osteoarthritis in these units were modeled with Cox proportional-hazards regression, separately for hip and knee and for the launch and the closure stage. Results - The unadjusted and adjusted hazard ratios (HRs) for total hip and knee replacements performed in the initial stage of activity of the units that were launched were similar to the reoperation risks in patients who were operated in these units after the early stage of activity. The unadjusted and risk-adjusted HRs for early reoperation after total hip replacement (THR) were increased at the closure stage (adjusted HR = 1.8, 95% CI: 1.2-2.8). The reoperation risk at the closure stage after total knee replacement (TKR) was not increased. Interpretation - The results indicate that closure of units performing total hip replacements poses an increased risk of reoperation. Closures need to be managed carefully to prevent the quality from deteriorating when performing the final arthroplasties.Peer reviewe

Return to work after subacromial decompression, diagnostic arthroscopy, or exercise therapy for shoulder impingement : a randomised, placebo-surgery controlled FIMPACT clinical trial with five-year follow-up

Background: Arthroscopic subacromial decompression is one of the most commonly performed shoulder surgeries in the world. It is performed to treat patients with suspected shoulder impingement syndrome, i.e., subacromial pain syndrome. Only few studies have specifically assessed return-to-work rates after subacromial decompression surgery. All existing evidence comes from open, unblinded study designs and this lack of blinding introduces the potential for bias. We assessed return to work and its predictors in patients with shoulder impingement syndrome in a secondary analysis of a placebo-surgery controlled trial. Methods: One hundred eighty-four patients in a randomised trial had undergone arthroscopic subacromial decompression (n = 57), diagnostic arthroscopy, a placebo surgical intervention, (n = 59), or exercise therapy (n = 68). We assessed return to work, defined as having returned to work for at least two follow-up visits by the primary 24-month time point, work status at 24 and 60 months, and trajectories of return to work per follow-up time point. Patients and outcome assessors were blinded to the assignment regarding the arthroscopic subacromial decompression vs. diagnostic arthroscopy comparison. We assessed the treatment effect on the full analysis set as the difference between the groups in return-to-work rates and work status at 24 months and at 60 months using Chi-square test and the predictors of return to work with logistic regression analysis. Results: There was no difference in the trajectories of return to work between the study groups. By 24 months, 50 of 57 patients (88%) had returned to work in the arthroscopic subacromial decompression group, while the respective figures were 52 of 59 (88%) in the diagnostic arthroscopy group and 61 of 68 (90%) in the exercise therapy group. No clinically relevant predictors of return to work were found. The proportion of patients at work was 80% (147/184) at 24 months and 73% (124/184) at 60 months, with no difference between the treatment groups (p-values 0.842 and 0.943, respectively). Conclusions: Arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy or exercise therapy on return to work in patients with shoulder impingement syndrome. We did not find clinically relevant predictors of return to work either.Peer reviewe