Outcome of Contemporary Knee Arthroplasty : In terms of survivorship and patient reported outcome measures with special reference to patients less than 65 years of age

Pitkälle edenneen oireisen polvinivelrikon hoidossa tekonivelleikkauksen tulokset ovat erinomaiset: kipu lievittyy, ja sekä toimintakyky että myös elämänlaatu parantuvat merkittävästi. Tekonivelen hyvä pitkäaikaispysyvyys on lisännyt tämän hoitomenetelmän käyttöä pitkälle edenneen polven nivelrikon hoidossa myös nuoremmilla potilailla, vaikka toiminnalliset tulokset ja tekonivelen pysyvyys onkin raportoitu huonommaksi verrattuna vanhempiin potilaisiin. Sementtikiinnitystä voidaan pitää kultaisena standardina polven kokotekonivelleikkauksessa. Nuoremmilla, työikäisillä potilailla paras komponenttien kiinnitysmenetelmä on kuitenkin edelleen kiistanalainen. Polven tekonivelleikkausten ilmaantuvuus on lisääntynyt viimeisten vuosikymmenten aikana, ja ilmaantuvuuden kasvun on ennustettu edelleen jatkuvan lähitulevaisuudessa. Sekä leikkausaiheiden laajentuminen nuorempiin potilaisiin että toisaalta leikkausmäärien lisääntyminen nuoremmilla potilailla ovat lisänneet huolta siitä, että kasvaako myös uusintaleikkausten määrä merkittävästi lähivuosikymmeninä. Ilmaantuvuudessa on havaittu lisäksi eroja sekä maantieteellisesti että potilaiden ikäryhmien välillä. Suurin polven tekonivelleikkausten ilmaantuvuuden kasvu on havaittu nk. suurissa ikäluokissa. Työikäisillä potilailla on korkeat odotukset polven tekonivelleikkauksen tuloksesta, ja noin 11–25 % potilaista on tähänastisissa tutkimuksissa ollut tyytymättömiä leikkauksen tulokseen. Prospektiivista seurantatutkimusta aiheesta on kuitenkin julkaistu vain vähän. Leikkauksen yhteydessä annettava kipulääkitys sekä leikkauksen jälkeinen kivun hoito on yksi avaintekijä polven tekonivelleikkauksen onnistumissa. Hyvä kivun hoito mahdollistaa kunnollisen kuntoutusharjoittelun, vähentää leikkauksen jälkeisiä välittömiä komplikaatioita ja voi myös heijastua tuloksissa ja tyytyväisyydessä pitkällä aikavälillä. Tässä tutkimuksessa arvioitiin nykyisten polven tekonivelleikkausten ilmaantuvuutta, eri kiinnitysmenetelmien kestävyyttä ja työikäisten potilaiden tuloksia potilaiden raportoimilla vaikutusmittareilla. Lisäksi arvioitiin paikallispuudutuksen vaikutusta kivun hoitoon ja leikkauksen pitkäaikaistuloksiin. I:ssä ja II:ssa osatyössä käytettiin tutkimusaineistona Pohjoismaista tekonivelrekisteriä (NARA), joka koostuu Suomen, Ruotsin, Norjan ja Tanskan yhdistyneistä tekonivel- rekistereistä. I osatyö sisälsi 358 310 potilasta ja II osatyö 115 177 potilasta. III osatyön materiaali koostui Suomen tekonivelrekisterin aineistosta sisältäen 1 151 potilasta. IV osatyö oli puolestaan etenevä seurantatutkimus, jossa Tekonivelsairaala Coxassa polven tekonivelleikkauksen läpikäyneiden 232 potilaan leikkaustulokset arvioitiin 2 vuoden seurannassa. V osatyössä 60 potilasta satunnaistettiin Tekonivelsairaala Coxassa polven teko- nivelleikkauksessa saamaan joko LIA-puudute tai plaseboinjektio, ja heidän toipumistaan leikkauksesta seurattiin vuoden ajan tulokset rekisteröiden. Tässä tutkimuksessa todettiin, että polven tekonivelleikkausten kokonaisilmaantuvuus lisääntyi kaikissa Pohjoismaissa. Suomessa ilmaantuvuus oli erityisen suurta vuosina 2004–2006, mikä selittyy tuolloin voimaan tulleella hoitotakuulailla, joka ohjasi sairaaloita lyhentämään leikkausjonoja. Vaikka Pohjoismaissa väestön elintaso ja terveyden- huoltojärjestelmä ovat verrattavissa toisiinsa, olivat erot ilmaantuvuuksissa huomattavia. Ilmaantuvuuden lisääntyminen johtui pääosin nimenomaan kokotekonivelleikkausten lisääntymisestä. Osatekonivelleikkausten ilmaantuvuudessa oli maiden välillä huomatta- vaa vaihtelua, ja yli 65-vuotiaiden osatekonivelleikkausten ilmaantuvuus väheni selvästi Ruotsissa,. Sementtikiinnitteisillä ja nk. hybridi polvitekonivelillä oli erinomaiset pysyvyydet 10-vuoden seurannassa. Kaikilla kiinnitysmenetelmillä saavutettiin hyväksyttävät pysyvyydet, mutta muiden kuin sementtikiinnitteisten polven tekonivelten määrät tutkimuksessa olivat vähäisemmät, mikä vaikeuttaa ryhmien vertailua. Sementittömällä tantaalimetallisella säärikomponentilla todettiin erinomainen pysy- vyys eikä tekonivelen irtoamisen riski eronnut vastaavasta sementtikiinnitteisestä tekonivelmallista. Kaikissa PROM-mittareissa todettiin merkittävä paraneminen 2 vuoden seurannassa ja sekä fyysinen että psyykkinen toimintakyky lisääntyivät merkittävästi. Oireettomuus oli harvinaista. Potilaat, joiden radiologinen nivelrikko oli ennen leikkausta lievempi (KL2), olivat tyytymättömämpiä leikkauksen tulokseen kuin ne potilaat, joiden nivelrikko luokiteltiin pitkälle edenneeksi (KL3–4). Kokotekonivelellä ja osatekonivelellä hoidettujen potilaiden tuloksissa ei ollut eroa. Polven tekonivelleikkauksen yhteydessä annettu paikallispuudutus vähensi opiaattilääkityksen määrää merkittävimmin ensimmäisen 6 tunnin aikana. Se paransi myös polven liikelaajuutta heti leikkauksen jälkeen, mutta pitkäaikaisia vaikutuksia toiminnallisilla mittareilla ei havaittu 1 vuoden seurannassa. Vaikka polven tekonivelleikkausten ilmaantuvuus lisääntyi suhteessa eniten alle 65-vuotiailla potilailla, oli kokonaisilmaantuvuus kuitenkin edelleen selvästi suurempaa yli 65-vuotiailla. Tämän johdosta suurin osa polven tekonivelleikkauksista tehdään tule- vaisuudessakin vanhemmille ikäryhmille. Kuitenkin nuorempien potilaiden fyysinen aktiivisuus, vaatimustaso sekä moniulotteiset taustatekijät tyytyväisyyden taustalla muodostavat erityispiirteensä nuoremmilla potilailla. Kaikilla kiinnitysmenetelmillä saavutettiin erinomainen pysyvyys 10 vuoden seurannassa. Sementtikiinnitteistä polven tekoniveltä voidaan edelleen pitää kultaisena standardina huolimatta hybridin ja käänteisen hybridin hyvistä tuloksista työikäisillä potilailla. Tantaalimetallisella sementittömällä säärikomponentilla irtoaman riski on sementtikiinnitteistä vastaava. Polven tekonivelleikkauksella saavutetaan yleisesti ottaen merkittävä kivun lievitys ja toimintakyvyn parantuminen työikäisillä potilailla. Osalle potilaista voi kuitenkin jäädä sekä kipua että myös toimintakyvyn rajoitteita, ja erityisesti lieväasteinen nivelrikko ennen leikkausta on selkeä leikkaustulokseen tyytymättömyyttä lisäävä riskitekijä. Leikkauksen aikana annettava paikallispuudutus on tehokas lisä polven tekonivelleikkauksen jälkeiseen kivun hoitoon. Puudutuksella ei kuitenkaan ole vaikutusta leikkauksen lopputulokseen kivun ja toimintakyvyn osalta.In patients with symptomatic severe knee osteoarthritis (OA), total knee arthroplasty (TKA) has good long-term outcomes and results in greater pain relief and increased functional improvement compared with nonsurgical treatment. Because of good long-term implant survivorship, TKA also become a common treatment for severe knee OA among younger patients. However, the outcomes and implant survivorship of TKA have been reported to be inferior in younger patients. To date, cemented fixation has been regarded as the gold standard fixation method in TKA, but there has been controversy regarding the optimal fixation method among working-age patients. In many countries, reported increases in the rate of TKAs and estimates of future demand predict a substantial increase in the incidence of TKAs. Both a broadening of indications for younger patients and an increase in the total incidence of TKA have raised concerns over a possible increase in revision burden in the long-term. Differences between geographic location and age groups have been observed in the incidences of TKA. The major increase in incidence has been found in patients from the “baby boomer” (born between 1946 and 1964) generation. Working-age patients have high expectations for the outcome of TKA, and between 11 and 25% of these patients have been reported to be dissatisfied after the operation. These results, however, have been derived from studies without a true prospective observational set-up. Adequate postoperative pain management plays a key role in enabling proper early recovery after TKA. However, the effect of postoperative pain management on the final outcome of this operation in terms of function and quality of life is not well known. The aim of this study was to evaluate the incidence and outcomes of contemporary knee arthroplasty with special reference to working-age patients. Both the implant survivorship of different fixation methods of TKA and also patient-reported outcome measures (PROMs) were assessed. Secondly, we aimed to study the efficacy of local infiltration analgesia (LIA) and the effect of early pain management on the outcomes of TKA. In the study I, based on Nordic Arthroplasty Register Association (NARA) data, a total of 385 310 primary knee arthroplasties in patients aged 30 years or older performed in 4 Nordic countries were analyzed from 1997 to 2012 in Denmark, Norway, and Sweden, and from 2000 to 2012 in Finland. In the study II, 115 177 TKAs selected from NARA data in patients aged less than 65 years of age who had undergone an unconstrained primary TKA for primary OA from 2000 to 2016 were included to assess the survivorship of cemented, uncemented, hybrid, and inverse hybrid TKAs. In the study III, based on Finnish Arthroplasty Register (FAR) data, 1 151 TKAs that were performed between 2003 and 2010 using an uncemented porous tantalum metal (TM) tibial component were analyzed. In the study IV a total of 232 (254 knees) patients were enrolled between March 1st, 2012 and October 30th, 2014 for a prospective observational study to analyze the outcomes of knee arthroplasty using PROMs. In the study V a total of 60 patients who underwent unilateral TKA between March 2011 and March 2012 were enrolled into a randomized, double-blinded, placebo-controlled study to analyze the effect of LIA on early pain management and also on PROMs over a 1-year follow-up. There was an equal increase in total incidence, comprising both TKAs and unicondylar knee arthroplasties (UKA), in all countries. The increase in surgical procedures in Finland from 2004 to 2006 may be explained by the new social and health care law that forced hospitals to shorten patient waiting times for surgery. Despite having comparable socio-economic situations and health care systems, the differences in the incidence of knee arthroplasties between countries were notable. The total increase in the number of arthroplasties in all countries was mainly due to an increased incidence of TKAs. In Sweden, there was a significant decrease in the incidence of UKAs in patients 65 years or older. In Finland, Denmark, and Norway, variations in the incidences of UKAs were more heterogeneous. Both cemented and hybrid TKAs evinced excellent 10-year survival rates in patients aged less than 65 years in the Nordic countries. Even though hybrid/inverse hybrid versions of the well-performing contemporary TKA designs provided younger patients with a good mid-term outcome in our study, they were still only used in a limited number of patients. In the inverse hybrid group, one single TKA design comprised the vast majority of the whole group. An uncemented porous TM monoblock tibial component had excellent mid-term survivorship in a population-based setting in Finland. The most common reasons for revisions were instability and prosthetic joint infection (PJI). During the study period, only one revision was performed due to aseptic loosening of the tantalum monoblock tibial component. Neither age nor any of the other variables showed any effect on the risk of revision in the multivariate regression analyses. The mean Oxford Knee Score (OKS) and all the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales increased significantly (p<0.001) from the preoperative situation to 2-year follow-up in working-age patients who underwent knee arthroplasty at our institution. A significant increase (p<0.001) in physical activity was detected in High- Activity Arthroplasty Score (HAAS) and in RAND-36 Physical Component Score (PCS). Pain was also significantly (p<0.001) relieved during the follow-up. However, the total disappearance of pain was rare at 2 years. Patients with milder Kellgren-Lawrence (KL) grade 2 osteoarthritis (OA) were less satisfied and reported poorer PROM outcomes than those with advanced OA (KL 3–4). There was no difference in the outcome (any PROM) between patients who underwent total knee arthroplasty (TKA) and those who received unicondylar knee arthroplasty (UKA). A single intraoperative drug infiltration containing levobupivacaine, ketorolac, and adrenaline decreased the total consumption of oxycodone during the first 48 hours postoperatively. The effect of LIA was most pronounced during the first 6 hours postoperatively. LIA also improved the early knee ROM, but no long-term functional benefit was observed in PROMs. The increase in the overall incidence of knee arthroplasties was the consequence of an increase in incidence of TKAs, whereas the incidence of UKAs varied between countries. The proportional growth in incidence of TKAs during the study period was highest in patients younger than 65 years. Despite this, the incidence of knee arthroplasty in the youngest age group was clearly lower than in patients aged 65 years or older. Based on this finding, the majority of knee arthroplasties will probably be performed on elderly patients also in future. Even though knee arthroplasties were still performed clearly more often on patients aged 65 or older in Nordic countries, working-age patients should be considered as an important subgroup because of their higher physical activity, demands for surgery, and the multi-factorial reasons behind the success of TKA. Cemented TKA still merits the status of gold standard in TKA irrespective of the patients’ age. Even though hybrid/inverse hybrid versions of the well performing contemporary TKA designs provided younger patients with a good mid-term outcomes in our study, these results do not support the systematic use of these more expensive components in younger patients. Early loosening of uncemented TM tibial component was very rare and the risks for revision for other reasons were as rare as with contemporary cemented TKAs. TKA provided patients aged 65 years or less with clinically significant pain relief as well as improvements in ADL and quality of life. The patients´ physical activity was low or moderate preoperatively but improved significantly during the 2-year follow-up. Some pain and functional deficiencies remained after knee arthroplasty, and this should be emphasized in the preoperative guidance given to patients who are considering or who are scheduled for such surgery. Mild radiographic OA preoperatively is a clear risk factor for patient dissatisfaction after knee arthroplasty. A single perioperative infiltration of LIA reduced opiate consumption until 48 hours after TKA, and the routine use of perioperative infiltration analgesia as an adjunct to oral pain medication may be recommended in patients undergoing TKA. The use of LIA did not have any effect on the functional outcome of TKA over the first postoperative year

Good mid-term outcome of the rotating hinge knee in primary total knee arthroplasty - Results of a single center cohort of 106 knees with a median follow-up of 6.3 years

Background: The prognosis of complex primary total knee arthroplasty (TKA) with severe deformity and ligament deficiency is not clear. There is a paucity of evidence in the current literature on treatment outcomes of the rotating hinge knee implants in primary TKA. The aim of this study was to determine the mid-term clinical, radiographic, and health-related quality of life (HRQoL) outcomes in patients who had undergone complex primary TKA using single hinged knee replacement. Methods: In total, 106 complex primary TKAs (101 patients) were performed using the single rotating hinged knee (RHK) implant design at our institution between January 2004 and December 2013. We conducted a retrospective analysis of prospectively collected outcome data of these patients, obtaining also information on all possible revision surgeries from the Finnish Arthroplasty Register, and conducted a prospective follow-up study of all living patients. Results: The 10-year Kaplan-Meier survival rate of the RHK knees was 91.6% (95% CI 86.0% to 97.2%) with revision for any reason as the endpoint. Overall, eight knees (7.5 %) underwent revision surgery during the follow-up. None of the unrevised RHK knees were radio-graphically loose. The majority of patients evinced good clinical outcome and quality of life as measured with patient reported outcome measures. Conclusion: The hinge knee replacement which was assessed current study can be regarded as a suitable option in complex primary TKA, provided adequate attention is paid to the correct indications and patient selection. (C) 2020 Elsevier B.V. All rights reserved.Peer reviewe

Thicker polyethylene inserts (≥ 13 mm) increase the risk for early failure after primary cruciate-retaining total knee arthroplasty (TKA) : a single-centre study of 7643 TKAs

PURPOSE: This study investigates whether thicker (PE) inserts lead to a greater risk for revision after TKA. The differences between the TKA designs of three manufacturers (NexGen, PFC Sigma, Triathlon) are also compared. METHODS: A total of 7643 primary TKA surgeries were included. PE inserts were divided into two groups-"thick PE inserts" with a thickness of 13 mm (mm) or more and "standard PE inserts" with a thickness of less than 13 mm. Three cruciate-retaining (CR) TKA designs (NexGen, PFC Sigma, Triathlon) were included in the study. The differences in failure rates between groups were investigated using Kaplan-Meier survival curves and Cox regression model with hazard ratios (HR). Failure rates were investigated short-term ( 2 years; HR 1.6, CI 1.1 to 2.3) follow-up. The highest revision rate was observed in patients who received the Triathlon TKA with a thicker PE insert (HR 2.6, CI 1.2 to 5.7). CONCLUSION: The results indicate that thicker PE inserts are associated with increased risk for revision in primary TKA. Further research is required to ascertain whether more conformed PE inserts or constrained knee designs instead of thick CR inserts will ultimately lead to better clinical outcomes. LEVEL OF EVIDENCE: III.publishedVersionPeer reviewe

Different incidences of knee arthroplasty in the Nordic countries.

To access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked FilesBackground and purpose - The annual number of total knee arthroplasties (TKAs) has increased worldwide in recent years. To make projections regarding future needs for primaries and revisions, additional knowledge is important. We analyzed and compared the incidences among 4 Nordic countries Patients and methods - Using Nordic Arthroplasty Register Association (NARA) data from 4 countries, we analyzed differences between age and sex groups. We included patients over 30 years of age who were operated with TKA or unicompartmental knee arthroplasty (UKA) during the period 1997-2012. The negative binomial regression model was used to analyze changes in general trends and in sex and age groups. Results - The average annual increase in the incidence of TKA was statistically significant in all countries. The incidence of TKA was higher in women than in men in all 4 countries. It was highest in Finland in patients aged 65 years or more. At the end of the study period in 2012, Finland's total incidence was double that of Norway, 1.3 times that of Sweden and 1.4 times that of Denmark. The incidence was lowest in the youngest age groups (< 65 years) in all 4 countries. The proportional increase in incidence was highest in patients who were younger than 65 years. Interpretation - The incidence of knee arthroplasty steadily increased in the 4 countries over the study period. The differences between the countries were considerable, with the highest incidence in Finland. Patients aged 65 years or more contributed to most of the total incidence of knee arthroplasty.NordForsk gran

Translation and validation of the 12-item Oxford knee score for use in Finland

BioMed Central open acces

The effect of fixation type on the survivorship of contemporary total knee arthroplasty in patients younger than 65 years of age: a register-based study of 115,177 knees in the Nordic Arthroplasty Register Association (NARA) 2000-2016

Background and purpose - Cemented fixation is regarded as the gold standard in total knee arthroplasty (TKA). Among working-age patients, there has been controversy regarding the optimal fixation method in TKA. To address this issue, we conducted a register-based study to assess the survivorship of cemented, uncemented, hybrid, and inverse hybrid TKAs in patients aged Patients and methods - We used the Nordic Arthroplasty Register Association data of 115,177 unconstrained TKAs performed for patients aged Results - The 10-year KM survivorship of cemented TKAs was 93.6% (95% CI 93.4-93.8), uncemented 91.2% (CI 90.1-92.2), hybrid 93.0% (Cl 92.2-93.8), and inverse hybrid 96.0% (CI 94.1-98.1). In the Cox model, hybrid TKA showed decreased risk of revision after 6 years' follow-up compared with the reference group (cemented) (hazard ratio [HR] 0.5 [CI 0.4-0.8]), while uncemented TKAs showed increased risk of revision both 6 years' (HR 1.3 [1.0-1.7]) follow-up compared to the reference. Interpretation - Both cemented and hybrid TKAs had 10-year survival rates exceeding 92->93% in patients aged < 65 years. Cemented TKA, however, was used in the vast majority (89%) of the operations in the current study. As it performs reliably in the hands of many, it still deserves the status of gold standard for TKA in working-age patients.</div

Impact of the Nordic Arthroplasty Register Association (NARA) collaboration on demographics, methods and revision rates in knee arthroplasty : a register-based study from NARA 2000–2017

Background and purpose — We have previously observed differences in treatment and outcome of knee arthroplasties in the Nordic countries. To evaluate the impact of Nordic collaboration in the last 15 years we aimed to compare patient demographics, methods, and revision rates in primary knee arthroplasties among the 4 Nordic countries. Patients and methods — We included 535,051 primary knee arthroplasties reported 2000–2017 from the Nordic Arthroplasty Register Association (NARA) database. Kaplan–Meier analysis (KM) and restricted mean survival time (RMST) analysis were used to evaluate the cumulative revision rate (CRR) and RMST estimates with 95% confidence intervals (CI) and to compare countries in relation to risk of revision for any reason. Results — After 2010, the increase in incidence of knee arthroplasty plateaued in Sweden and Denmark but contin-ued to increase in Finland and Norway. In 2017 the incidence was highest in Finland with 226 per 105 person-years, while it was less than 150 per 105 in the 3 other Nordic coun-tries. In total knee arthroplasties performed for osteoarthri-tis (OA), overall CRR at 15 years for revision due to any reason was higher in Denmark (CRR 9.6%, 95% CI 9.2−10), Norway (CRR 9.1%, CI 8.7−9.5), and Finland (CRR 7.0%, CI 6.8−7.3) compared with Sweden (CRR 6.6%, CI 6.4−6.8). There were differences among the countries in use of implant brand and type, fixation, patellar component, and use of unicompartmental knee arthroplasty. Interpretation — We evinced a slowing growth of incidence of knee arthroplasties in the Nordic countries after 2010 with Finland having the highest incidence. We also noted substantial differences among the 4 Nordic countries, with Sweden having a lower risk of revision than the other countries. No impact of NARA could be demonstrated and CRR did not improve over time.publishedVersionPeer reviewe

Mild knee osteoarthritis predicts dissatisfaction after total knee arthroplasty : a prospective study of 186 patients aged 65 years or less with 2-year follow-up

Background and aims: The incidence of total knee arthroplasty (TKA) is increasing, especially among younger working-age patients. However, dissatisfaction rates in this population are higher than among older patients. The aim of this study was to assess the rates of dissatisfaction and persistent pain after TKA and to evaluate those factors that predict these outcomes. Material and methods: In total, 186 patients undergoing unilateral TKA aged 65 years or less were enrolled into this prospective observational study with 2-year follow-up. To assess the outcome, the visual analogue scales regarding satisfaction and persistent pain at rest and during exercise were used. In addition, the association between patients´ demographics, radiographic severity of knee osteoarthritis (OA), patient-reported outcome measures (PROMs) and dissatisfaction and persistent pain were tested by univariate logistic regression analysis. Mild OA was defined as Kellgren-Lawrence (KL) grade 2 and severe OA as KL grade 3–4. Furthermore, multiple logistic regression analysis was also conducted to test statistically significant relations. Results: After 2 years, 12 % (n = 23) of patients were dissatisfied with the outcome of TKA, 27 % (n = 50) reported persistent pain during exercise and 10 % (n = 18) at rest. Patients with mild knee OA were significantly more dissatisfied (28.6 %) than patients with more severe OA (8.7 %) (p = 0.003). Younger patients had an increased risk for both dissatisfaction and persistent pain. Apart from KOOS Quality of Life, poor preoperative KOOS subscores were also predictive for these outcomes. Conclusion: Mild radiographic knee OA was the main predicting factor for dissatisfaction after TKA. Thus, performing TKA for such patients should be carefully considered. Furthermore, these patients should be informed about the increased risk for dissatisfaction and the same seems to apply to younger patients. Interestingly, when TKA is performed for patients with more severe knee OA, the satisfaction rates seem to be somewhat higher than those previously reported. Trial registration: The study was retrospectively registered with ClinicalTrials.gov (registration number NCT03233620) on 28 July 2017.publishedVersionPeer reviewe

Timothy and tall fescue mixtures increase forage yield and improve yield quality in comparison with timothy in Finland

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Seminaarin järjestäjät: MTT, Pelto Tuottamaan -hanke; Suomen Nurmiyhdistys r.y.vokKA