Surgical versus non-surgical interventions for treating patellar dislocation

Background: Patellar dislocation occurs when the patella disengages completely from the trochlear (femoral) groove. Following reduction of the dislocation, conservative (non-surgical) rehabilitation with physiotherapy may be used. Since recurrence of dislocation is common, some surgeons have advocated surgical intervention rather than non-surgical interventions. This is an update of a Cochrane review first published in 2011. Objectives: To assess the effects (benefits and harms) of surgical versus non-surgical interventions for treating people with primary or recurrent patellar dislocation. Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, AMED, CINAHL, ZETOC, Physiotherapy Evidence Database (PEDro) and a variety of other literature databases and trial registries. Corresponding authors were contacted to identify additional studies. The last search was carried out in October 2014. Selection criteria: We included randomised and quasi-randomised controlled clinical trials evaluating surgical versus non-surgical interventions for treating lateral patellar dislocation. Data collection and analysis: Two review authors independently examined titles and abstracts of each identified study to assess study eligibility, extract data and assess risk of bias. The primary outcomes we assessed were the frequency of recurrent dislocation, and validated patient-rated knee or physical function scores. We calculated risk ratios (RR) for dichotomous outcomes and mean differences MD) for continuous outcomes. When appropriate, we pooled data. Main results: We included five randomised studies and one quasi-randomised study. These recruited a total of 344 people with primary (first-time) patellar dislocation. The mean ages in the individual studies ranged from 19.3 to 25.7 years, with four studies including children, mainly adolescents, as well as adults. Follow-up for the full study populations ranged from two to nine years across the six studies. The quality of the evidence is very low as assessed by GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) criteria, with all studies being at high risk of performance and detection biases, relating to the lack of blinding. There was very low quality but consistent evidence that participants managed surgically had a significantly lower risk of recurrent dislocation following primary patellar dislocation at two to five years follow-up (21/162 versus 32/136; RR 0.53 favouring surgery, 95% confidence interval (CI) 0.33 to 0.87; five studies, 294 participants). Based on an illustrative risk of recurrent dislocation in 222 people per 1000 in the non-surgical group, these data equate to 104 fewer (95% CI 149 fewer to 28 fewer) people per 1000 having recurrent dislocation after surgery. Similarly, there is evidence of a lower risk of recurrent dislocation after surgery at six to nine years (RR 0.67 favouring surgery, 95% CI 0.42 to 1.08; two studies, 165 participants), but a small increase cannot be ruled out. Based on an illustrative risk of recurrent dislocation in 336 people per 1000 in the non-surgical group, these data equate to 110 fewer (95% CI 195 fewer to 27 more) people per 1000 having recurrent dislocation after surgery. The very low quality evidence available from single trials only for four validated patient-rated knee and physical function scores (the Tegner activity scale, KOOS, Lysholm and Hughston VAS (visual analogue scale) score) did not show significant differences between the two treatment groups. The results for the Kujala patellofemoral disorders score (0 to 100: best outcome) differed in direction of effect at two to five years follow-up, which favoured the surgery group (MD 13.93 points higher, 95% CI 5.33 points higher to 22.53 points higher; four studies, 171 participants) and the six to nine years follow-up, which favoured the non-surgical treatment group (MD 3.25 points lower, 95% CI 10.61 points lower to 4.11 points higher; two studies, 167 participants). However, only the two to five years follow-up included the clear possibility of a clinically important effect (putative minimal clinically important difference for this outcome is 10 points). Adverse effects of treatment were reported in one trial only; all four major complications were attributed to the surgical treatment group. Slightly more people in the surgery group had subsequent surgery six to nine years after their primary dislocation (20/87 versus 16/78; RR 1.06, 95% CI 0.59 to 1.89, two studies, 165 participants). Based on an illustrative risk of subsequent surgery in 186 people per 1000 in the non-surgical group, these data equate to 11 more (95% CI 76 fewer to 171 more) people per 1000 having subsequent surgery after primary surgery. Authors' conclusions: Although there is some evidence to support surgical over non-surgical management of primary patellar dislocation in the short term, the quality of this evidence is very low because of the high risk of bias and the imprecision in the effect estimates. We are therefore very uncertain about the estimate of effect. No trials examined people with recurrent patellar dislocation. Adequately powered, multi-centre, randomised controlled trials, conducted and reported to contemporary standards, are needed. To inform the design and conduct of these trials, expert consensus should be achieved on the minimal description of both surgical and non-surgical interventions, and the anatomical or pathological variations that may be relevant to both choice of these interventions and the natural history of patellar instability. Furthermore, well-designed studies recording adverse events and long-term outcomes are needed

Bioabsorbable Versus Metal Screw in the Fixation of Tibial Tubercle Transfer

Peer reviewe

Saaristopolitiikan arviointi

Saaristopolitiikan arviointiraportin tavoitteena on tukea voimassa olevan valtakunnallisen saaristo-ohjelman toteuttamista sekä pohjustaa tulevien kausien ja ohjelmien valmistelua. Lisäksi tavoitteena on tuottaa näkemyksiä siitä, miten saaristopolitiikkaa pitäisi kehittää, sillä saaristopolitiikalta odotetaan uudistumista ja asemoitumista muihin keskeisiin politiikka-aloihin nähden. Saaristopolitiikan päästrategiana on vaikuttaa muilla politiikkalohkoilla tehtäviin saaristoa koskeviin päätöksiin siten, että saariston erityisolosuhteet tulevat huomioiduksi. Saaristoasiain neuvottelukunta toimii saaristoa koskevien asioiden kansallisen tason edunvalvojana ja vaikuttajana. Parlamentaarinen menettelytapa edistää saaristoasiain neuvottelukunnan toimintakykyä ja vaikutusvaltaa, minkä ansiosta saaristopolitiikka näyttäytyy ”kokoaan suurempana”. Saaristopolitiikka on pääasiassa kansallisen tason edunvalvontaa ja vaikuttamista, ja se heijastuu kuntatasolle lähinnä saaristolisien ja liikenneratkaisujen kautta. Saaristoalueille suuntautuvat kehittämisvarat ja -toiminta eivät ole saaristopolitiikkaa vaan saariston ja maaseudun kehittämistä. Saaristopolitiikan näkyvyyttä kannattaa lisätä esim. toimintaryhmien ja maaseuturahaston hanketoiminnassa. Saaristopolitiikan tulevaisuuteen vaikuttaa maakuntauudistuksen jälkeen maakuntien rahoituksen ja mielenkiinnon riittävyys saaristoalueita kohtaan

Utvärdering av skärgårdspolitiken

Målet för utvärderingsrapporten är att bidra till att genomföra det gällande nationella skärgårdsprogrammet och lägga en grund för beredning av framtida perioder och program. Ett ytterligare mål är att ta fram synpunkter på hur skärgårdspolitiken borde utvecklas eftersom man förväntar sig att skärgårdspolitiken förnyar sig och positionerar sig visavi andra centrala politikområden. Skärgårdspolitikens huvudstrategi handlar om att påverka de beslut om skärgården som fattas inom andra politiska områden så att särförhållanden i skärgården beaktas. Skärgårdsdelegationen har rollen som intressebevakare och påverkare i skärgårdsfrågor på nationell nivå. Det parlamentariska förfaringssättet främjar skärgårdsdelegationens funktionsförmåga och inflytande. Därför förefaller skärgårdspolitiken vara ”större än den är”. Skärgårdspolitiken är huvudsakligen intressebevakning och påverkande på nationell nivå. Den återspeglas på den kommunala nivån närmast i form av skärgårdstilläggen och trafikbeslut. Skärgårdsområdenas utvecklingsmedel och -verksamhet ses inte som skärgårdspolitik, utan som utveckling av skärgården och landsbygden. Det är värt att ge skärgårdspolitiken mer synlighet till exempel genom projektaktivitet i aktionsgrupper och via landsbygdsfonden. Efter landskapsreformen påverkas skärgårdspolitikens framtid av landskapens tillräckliga finansiering och intresse för skärgårdsområdena

Utvärdering av skärgårdspolitiken

Målet för utvärderingsrapporten är att bidra till att genomföra det gällande nationella skärgårdsprogrammet och lägga en grund för beredning av framtida perioder och program. Ett ytterligare mål är att ta fram synpunkter på hur skärgårdspolitiken borde utvecklas eftersom man förväntar sig att skärgårdspolitiken förnyar sig och positionerar sig visavi andra centrala politikområden. Skärgårdspolitikens huvudstrategi handlar om att påverka de beslut om skärgården som fattas inom andra politiska områden så att särförhållanden i skärgården beaktas. Skärgårdsdelegationen har rollen som intressebevakare och påverkare i skärgårdsfrågor på nationell nivå. Det parlamentariska förfaringssättet främjar skärgårdsdelegationens funktionsförmåga och inflytande. Därför förefaller skärgårdspolitiken vara ”större än den är”. Skärgårdspolitiken är huvudsakligen intressebevakning och påverkande på nationell nivå. Den återspeglas på den kommunala nivån närmast i form av skärgårdstilläggen och trafikbeslut. Skärgårdsområdenas utvecklingsmedel och -verksamhet ses inte som skärgårdspolitik, utan som utveckling av skärgården och landsbygden. Det är värt att ge skärgårdspolitiken mer synlighet till exempel genom projektaktivitet i aktionsgrupper och via landsbygdsfonden. Efter landskapsreformen påverkas skärgårdspolitikens framtid av landskapens tillräckliga finansiering och intresse för skärgårdsområdena

Maaseutuohjelma 2014–2020 – arviointi innovointi-, koulutus- ja yhteistyövaikutuksista

Arvioinnissa tarkastellaan Manner-Suomen maaseudun kehittämisohjelman 2014–2020 koulutus- ja yhteistyötoimenpiteiden tuloksia ja vaikutuksia sekä esitetään yleisarvio innovaatioiden edistymisestä maaseutuohjelmassa. Tapaustarkasteluissa käsitellään Suomen metsäkeskuksen hanketoimintaa ja maaseudun innovaatio- eli EIP-ryhmiä. Arvioinnin toteutti arviointiryhmä, johon kuuluivat Alue- ja kuntatutkimuskeskus Spatia aluekehittämisen konsulttitoimisto MDI ja asiantuntijayritys TK-Eval. Maaseutuohjelmassa innovaatiot ymmärretään teknologisina, sosiaalisina ja institutionaalisina uudistuksina, jotka tuottavat ratkaisuja maaseutualueita koskeviin kehittämiskysymyksiin. Tämä kehittämistavoite on moniulotteinen ja siihen pyritään vaikuttamaan monin eri keinoin. Maaseutuohjelman koulutus- ja tiedonvälitystoimenpide ja yhteistyötoimenpide ovat tämän innovaatiostrategian toimeenpanon keskeiset työkalut. Koulutus- ja tiedonvälityshankkeiden toteutus oli pääpiirteittäin edennyt suunnitellusti ja asetettujen indikaattoreiden mukaisesti. Osaamisen lisääminen on ollut tärkeää kaikilla toimialoilla. Yhteistyöhankkeita on suunnattu runsaasti pienyritysten toiminnan kehittämiseen, maaseutualueiden paikallisen kehittämisen edistämiseen ja alkutuottajien parempaan kytkentään ruokaketjuun

Machining of Aluminium with MHz High-Intensity Focused Ultrasound

Cavitation-induced surface erosion has been studied for decades. High-intensity focused ultrasound (HIFU) enables localized erosion, with applications in many fields. However, no research has been published on machining solely with HIFU. Compared to existing micro-machining technologies, HIFU exhibits a unique set of benefits: inexpensive, minimal maintenance due to non-contact machining without slurry, mitigated chemical load, and monitoring capability. We demonstrate controlled surface machining of mirror-polished aluminium (AW-5754) using high-frequency (12 MHz) HIFU-induced cavitation erosion. Optimal sonication parameters (transducer-sample distance, amplitude, cycles per burst, number of bursts, and pulse repetition frequency) for stationary surface erosion were first identified experimentally. These parameters served as a basis for studying the effect of sonication parameters during on-the-fly erosion, i.e., engraving lines. The effect of stage translation velocity and the number of repeated passes across the engraved line were also studied. Subsequently, the acronym of our laboratory, “ETLA”, was engraved, with a 500 µm letter height and an average line width of 53 µm.Peer reviewe

Quantifying the Role of Transport by Acoustic Streaming in MHz Focused-Ultrasound-Based Surface Sampling

We have developed an ultrasound-based surface sampling method permitting surface studies for liquid immersed samples. The method employs high-intensity focused ultrasound, which can remove material from predetermined areas and induce acoustic streaming that causes the immersion liquid to flow. In this study, we studied several conditions of acoustic streaming, which can affect particle transport away from the sampled surface. First, we explored suitable acoustic streaming conditions by finite element modelling. Next, we measured the induced streaming fields by particle image velocimetry. This study comprised cases, when a high-intensity focused ultrasound beam encountered a solid surface at different transducer-surface distances. A change in direction of streaming occurred when a focusing transducer was moved from −2λ defocus to -4λ defocus (towards the surface). Thus, we found suitable conditions for an upwards directing acoustic streaming field. This kind of defocus condition can be coupled to the surface sampling process allowing efficient particle transport for subsequent chemical analysis.Peer reviewe

Identifying Regions-of-Interest and Extracting Gold from PCBs Using MHz HIFU

Increased digitalization and technological development raises the demand for rare and precious metals (RPM). Due to their rarity, mining RPMs from the earth is becoming increasingly difficult. Traditional urban mining methods to recover RPMs from printed circuit boards (PCB) need to separate the RPMs from non-metallic substances, e.g. plastic. This separation requires toxic substances and causes unwanted and toxic by-products and emissions. The ability to identify regions-of-interest on PCBs, i.e. the gold pads, and to extract RPMs from only the desired areas would reduce the need for toxic substances. In this study, a single 12 MHz high-intensity focused-ultrasound transducer was used to 1) image a PCB to locate the gold pads, and 2) to subsequently induce inertial cavitation to remove gold from three extraction areas on the selected gold pad. The sonication was performed in water without additional chemicals. Gold removal was verified by imaging the pad with a coded-excitation scanning acoustic microscope (fc = 375 MHz). Average areas and volumes of the three extraction regions were A = (12.2 ± 0.5)·103 μm2 and V = (18 ± 2)·103 μm3, respectively. The total amount of removed gold and nickel (from beneath the gold plating) from all three extraction areas was estimated to mAu,tot = (570 ± 20) ng and mNi,tot = (440 ± 30) ng. This study constitutes a first step towards more environmentally friendly, non-toxic urban mining of RPMs.Peer reviewe