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Objective: A novel preoperative procedure From Home To Operation (FHTO) seeks to combat increasing operation and infection rates. This is the first prospective randomized controlled trial (RCT) comparing the cost-effectiveness and cost-utility of FHTO and conventional ward procedures for standardized Laparoscopic Cholecystectomy (LC).Research Design and Methods: During 12/2004-7/2005, 47 patients with symptomatic gallstones were randomized to receive LC in the FHTO (28 patients) or in a conventional manner (19 patients) in a Finnish hospital setting. The 15D quality of life tool was administered at the baseline and 1 month after.Main Outcome Measures: A stochastic approach over a month interval for hospital costs, length of postoperative stay, infection rate and Quality-Adjusted Life Years (QALY) was employed.Results: Baseline group characteristics were similar. The mean health care costs with FHTO (1695 EUR) were significantly lower (p < 0.001) than in the conventional arm (2234 EUR). The number of patients discharged on the first postoperative day was 27 (96.4%) and 15 (78.9%) with two (7.1%) infections in the FHTO and four (21.1%) in the conventional arm. A difference in QALYs gained (0.0174; p = 0.030) favouring FHTO was observed. According to a cost-effectiveness acceptability curve, the probability of FHTO being cost-effective was 99%. The results were robust to probabilistic sensitivity analyses.Conclusions: FHTO can introduce substantial cost savings and have a positive impact on both clinical measures and quality of life. Studies with larger numbers of patients are needed to assess whether conventional ward procedure can be a source of infections, which can be avoided with FHTO.Clinical Trial Registry: ICJME-qualified registry of the Hospital District of Helsinki and Uusimaa (number 217849). [ABSTRACT FROM AUTHOR]

Objective To study the long-term outcome of arthroscopy in patients with chronic patellofemoral pain syndrome (PFPS), the authors conducted a randomised controlled trial. The authors also investigated factors predicting the outcome in patients with PFPS. Methods Fifty-six patients with PFPS were randomised into two groups: an arthroscopy group (N=28), treated with knee arthroscopy and an 8-week home exercise programme, and a control group (N=28), treated with a similar 8-week home exercise programme only. The primary outcome was the Kujala score on pain and function at 5-year. Secondary outcomes were visual analogue scales (VASs) to assess activity-related symptoms. Results According to the Kujala score, both groups showed a marked improvement during the 5-year follow-up: a mean improvement of 14.7 (95% CI 9.9 to 19.4) in the arthroscopy group and 13.5 (95% CI 8.1 to 18.8) in the controls. No differences between the groups in mean improvement in the Kujala score (group difference 1.2 (95% CI -8.4 to 6.1)) or in the VAS scores were found. None of the investigated factors predicted the long-term outcome, but in most of the cases the treatment result immediately after the exercise programme remained similar also after the 5-year follow-up. Conclusion Our RCT, being the first of its kind, indicates that the 5-year outcome in most of the patients with chronic PFPS treated with knee arthroscopy and home exercise programme or with the home exercise programme only is equally good in both groups. Some of the patients in both groups do have long-term symptoms. Trial registration Current Controlled Trials ISRCTN 41800323. [ABSTRACT FROM AUTHOR]

Background: Some have recommended surgical treatment of Grade-III lateral ligament injuries in very active individuals with high functional demands on the ankle. The purpose of this study was to establish whether surgery provides better long-term results than functional treatment for acute ruptures of the lateral ligaments of the ankle.Methods: Physically active Finnish men (mean age, 20.4 years) with an acute Grade-III lateral ligament rupture of the ankle were randomly allocated to surgical (n = 25) or functional (n = 26) treatment. Ligament injury was confirmed with stress radiographs. Surgical treatment comprised suture repair of the injured ligament(s) within the first week after injury. A below-the-knee plaster cast was worn for six weeks with full weight-bearing. Functional treatment consisted of the use of an Aircast ankle brace for three weeks. The main outcome measures included final follow-up examinations, calculation of an ankle score, stress radiographs, and magnetic resonance imaging scans.Results: Fifteen (60%) of twenty-five surgically treated patients and eighteen (69%) of twenty-six functionally treated patients returned for long-term follow-up (mean duration, fourteen years). All patients in both groups had recovered their preinjury activity level and reported that they could walk and run normally. The prevalence of reinjury was one of fifteen in the surgical group and seven of eighteen in the functional treatment group (risk difference: 32%; 95% confidence interval: 6% to 58%). The mean ankle score did not differ significantly between the groups (mean difference: 8.3 points; 95% confidence interval: -0.03 to 16.6 points). Stress radiographs revealed no difference between groups with regard to the mean anterior drawer (-1 mm in the surgical group and 0 mm in the functional treatment group; mean difference: 0.7 mm; 95% confidence interval: -1.4 to 2.7 mm) or mean tilt angle (0° in both groups; mean difference: 0.1°; 95% confidence interval: -3.2° to 3.5°). Grade-II osteoarthritis was observed on magnetic resonance images of four of the fifteen surgically treated patients and in none of the eighteen functionally treated patients (risk difference: 27%; 95% confidence interval: 4% to 49%).Conclusions: These findings indicate that, in terms of recovery of the preinjury activity level, the long-term results of surgical treatment of acute lateral ligament rupture of the ankle correspond with those of functional treatment. Although surgery appeared to decrease the prevalence of reinjury of the lateral ligaments, there may be an increased risk for the subsequent development of osteoarthritis. [ABSTRACT FROM AUTHOR]

Abstract Background Arthroscopy is often used to treat patients with chronic patellofemoral pain syndrome (PFPS). As there is a lack of evidence, we conducted a randomized controlled trial to study the efficacy of arthroscopy in patients with chronic PFPS. Methods A total of 56 patients with chronic PFPS were randomized into two treatment groups: an arthroscopy group (N = 28), treated with knee arthroscopy and an 8-week home exercise program, and a control group (N = 28), treated with the 8-week home exercise program only. The arthroscopy included finding-specific surgical procedures according to current recommendations. The primary outcome was the Kujala score on patellofemoral pain and function at 9 months following randomization. Secondary outcomes were visual analog scales (VASs) to assess activity-related symptoms. We also estimated the direct healthcare costs. Results Both groups showed marked improvement during the follow-up. The mean improvement in the Kujala score was 12.9 (95% confidence interval (CI) 8.2–17.6) in the arthroscopy group and 11.4 (95% CI 6.9–15.8) in the control group. However, there was no difference between the groups in mean improvement in the Kujala score (group difference 1.1 (95% CI -7.4 - 5.2)) or in any of the VAS scores. Total direct healthcare costs in the arthroscopy group were estimated to exceed on average those of the control group by €901 per patient (p < 0.001). Conclusion In this controlled trial involving patients with chronic PFPS, the outcome when arthroscopy was used in addition to a home exercise program was no better than when the home exercise program was used alone. Trial registration Current Controlled Trials ISRCTN 41800323

Abstract Background Several quality-of-life studies in patients awaiting major joint replacement have focused on the outcomes of surgery. Interest in examining patients on the elective waiting list has increased since the beginning of 2000. We assessed health-related quality of life (HRQoL) in patients waiting for total hip (THR) or knee (TKR) replacement in three Finnish hospitals, and compared patients' HRQoL with that of population controls. Methods A total of 133 patients awaiting major joint replacement due to osteoarthritis (OA) of the hip or knee joint were prospectively followed from the time the patient was placed on the waiting list to hospital admission. A sample of controls matched by age, gender, housing and home municipality was drawn from the computerised population register. HRQoL was measured by the generic 15D instrument. Differences between patients and the population controls were tested by the independent samples t-test and between the measurement points by the paired samples t-test. A linear regression model was used to explain the variance in the 15D score at admission. Results At baseline, 15D scores were significantly different between patients and the population controls. Compared with the population controls, patients were worse off on the dimensions of moving (P < 0.001), sleeping (P < 0.001), sexual activity (P < 0.001), vitality (P < 0.001), usual activities (P < 0.001) and discomfort and symptoms (P < 0.001). Further, psychological factors – depression (P < 0.001) and distress (P = 0.004) – were worse among patients than population controls. The patients showed statistically significantly improved average scores at admission on the dimensions of moving (P = 0.026), sleeping (P = 0.004) and discomfort and symptoms (P = 0.041), but not in the overall 15D score compared with the baseline. In patients, 15D score at baseline (P < 0.001) and body mass index (BMI) (P = 0.020) had an independent effect on patients' 15D score at hospital admission. Conclusion Although patients' HRQoL did not deteriorate while waiting, a consistently worse HRQoL was observed in patients waiting for major joint replacement compared with population controls.

Background: The aim of this prospective randomized study was to evaluate the effect of waiting time (WT) on health-related quality of life (HRQoL), knee pain and physical function, and the use and costs of medication of patients awaiting total knee replacement., Methods: When placed on the waiting list, 438 patients were randomized into a short waiting time (SWT ≤ 3 months) or a nonfixed waiting time (NFWT > 3 months) group. HRQoL was measured by the 15D, and pain and physical function by modified Knee Society Clinical Rating System at baseline, admission, and 3 and 12 months postoperatively. The costs of medication due to osteoarthritis were calculated at the same measurement points. All analyses were performed using the intention-to-treat principle., Results: The mean WT was 94 and 239 days in the SWT and NFWT groups, respectively. Apart from higher weekly cost of medication in the SWT group at admission and better HRQoL in the NFWT group 1 year postoperatively, there were no statistically significant differences between the groups in other outcomes during the follow-up., Conclusion: Those in the SWT group had higher weekly costs of medication at admission, and reached better HRQoL 3 months earlier than those in the NFWT group, but the latter had better HRQoL after operation. Otherwise, the length of WT was not associated with different health and HRQoL outcomes in the groups., (© 2010, International Society for Pharmacoeconomics and Outcomes Research (ISPOR).)

Objective: This prospective randomized study assessed the effect of waiting time (WT) on health outcomes in Finnish patients admitted to hospital for primary total hip replacement (THR)., Methods: A total of 395 consecutive patients with a need for a primary THR because of osteoarthritis and who were placed on the waiting list between August 2002 and November 2003. After placement on the waiting list, the patients were randomly assigned to a short WT (

Background: Giant cell tumors of bone rarely metastasize but often recur locally after surgery. There is limited knowledge about the risk of recurrence related to different types of treatment., Patients and Methods: We analyzed factors affecting the local recurrence rate in 294 patients with giant cell tumors of the extremities using prospectively collected material from 13 centers. The median follow-up time was 5 (0.2-18) years., Results: A local recurrence was diagnosed in 57 of 294 patients (19%). The overall 5-year local recurrence rate was 0.22. Univariate analysis identified young age and intralesional surgery to be associated with a higher risk of recurrence. Based on multivariate analysis, the relative risk was 2.4-fold for intralesional surgery compared to more extensive operative methods. There was no correlation between tumor size, tumor extension, sex of the patient, tumor location, or fracture at diagnosis and outcome. In the subgroup of 200 patients treated with intralesional surgery, the method of filling (cement or bone) was known for 194 patients and was statistically highly significant in favor of the use of cement., Interpretation: Intralesional surgery should be the first choice in most giant cell tumors, even in the presence of a pathological fracture. After thorough evacuation, the cavity should be filled with cement.

Aims: To evaluate the effect of waiting on health-related quality of life (HRQoL), pain and physical function in patients awaiting primary total knee replacement (TKR) due to osteoarthritis., Methods: Some 438 patients awaiting TKR were randomized to a short waiting time (WT) group (< or =3 months) or a non-fixed WT group. In the final assessment, 310 patients (213 women) with a mean age of 68 years were included. HRQoL was measured on being placed on the waiting list and again at hospital admission using the generic 15D. Patients' self-report pain and physical function were evaluated using a scale modified from the Knee Society Clinical Rating System., Results: The median WTs for patients with short and non-fixed WT were 73 days (range 8-600 days) and 266 days (range 28-818 days), respectively. At admission, as assessed by the intention-to-treat analysis, there were no statistically significant differences between the groups in the 15D total score and disease-specific pain and function., Conclusions: Our study showed that longer WT did not result in worse pre-operative HRQoL.

Objective: To determine whether longer waiting time for major joint replacement is associated with health and social services utilization before treatment., Methods: When placed on the waiting list, patients were randomized to short (

Neurofibromatosis type 1 (NF1) is an inherited disease with an incidence of about 1:3000 worldwide. Approximately half of all patients with NF1 present osseous manifestations, which can vary from mild to severely debilitating changes such as congenital pseudarthrosis. In the present study, fracture healing of mouse tibia was followed and specimens were collected 5, 9, 14, and 22 days postoperatively. Experimental pseudarthrosis of rat was followed up to 15 weeks postoperatively. In situ hybridization and immunohistochemistry were used to demonstrate expression of NF1 tumor suppressor and phosphorylated p44/42 mitogen-activated protein kinase (MAPK), an indicator of the Ras-MAPK pathway. The results showed that ossified callus was formed in mouse fracture 22 days after the operation. The final outcome of rat pseudarthrosis was detected 9 weeks after the operation, presenting abundant cartilaginous callus at the pseudarthrosis. NF1 gene expression was noted in the maturing and in the hypertrophic cartilages during normal mouse fracture healing, and in rat pseudarthrosis. Phosphorylated p44/42 MAPK was detected in a subpopulation of the hypertrophic chondrocytes in both models. Furthermore, positive labeling for NF1 mRNA and protein was detected in endothelium in both the pseudarthrosis and in the fracture. In conclusion, NF1 gene expression and function are needed for normal fracture healing, possibly restraining excessive Ras-MAPK pathway activation.

We studied in a rat pseudoarthrosis model the time sequence of expression and distribution of fibronectin and collagens I, II, III and V. Collagens and fibronectin were immunolocalized at the light microscopic level. The major difference from the normal healing pattern was the extension of collagen II and cartilage into the interfragmentary area and at the circumference of the periosteal callus, without any bridging chondral or bony elements in the fracture gap. The formation of a fibrous bond, consisting mostly of collagen III and fibronectin, was observed. This speaks in favor of the failure of the multipotentional mesenchymal stem cells to change the fracture-healing process towards fibroblast proliferation and the production of tissue unable to mineralize. The decisive zone for mineralization of the callus appeared to be the area of the hypertrophied chondrocytes near the periosteal ossification front.

Background and Aims: Although the early phases of the healing seem to occur normally, the persistent rotational instability between the fracture fragments combined to periosteal manipulation at the fracture site cause a failure in the restoration process of bone; i.e. the bridging event of the fracture ends does not occur and the tissue in the interfragmentary area is not mineralized. A nonunion with a soft tissue connection between the fragments is formed without restoration of the biomechanical characteristics of the bone., Material and Methods: A nonunion model of the rat femur was employed to study the mineralization process of developing pseudoarthrosis using the sequential polychrome labeling and conventional histological hard tissue staining with Masson-Goldner trichrome method., Results and Conclusions: The same results of this study are in accordance with previous studies using the same nonunion model and suggest that if sufficient mechanical stability between the fracture fragments has not been achieved within optimal time period, the chondral phase of the callus is extended and the mineralization process of the hypertrophied chondrocytes is retarded and finally extinguished and the fracture gap is filled with non-mineralizing connective tissue.

A 37-yr-old, previously healthy officer developed a severe pain in the right shoulder and parethesia in the right I-III fingers during a high-altitude low-opening parachute jump. The pain started after a sudden neck flexion while he was checking the developing canopy, well before landing. Electroneuromyography revealed damage to the right C7 nerve root. Cervical radiography showed severe spondylosis and discus degeneration in the CV-VII region; magnetic resonance image demonstrated posterior disk protrusions in this area. Military aviators flying high-performance aircraft often have similar problems in the cervical spine; they have been attributed to effects of high + Gz forces in association with twisted head positions. Parachutists appear to face similar risks. Selection of the optimal head position during the parachute opening and use of light helmets should be emphasized.

An association between dental and other bacterial infections and coronary heart disease has recently been observed in both cross-sectional and longitudinal studies. To elucidate this topic, the severity of dental infections and coronary atheromatosis was assessed, together with measurements of the conventional coronary risk factors, in 100 individuals (88 men, 12 women, mean age 48, range 28-68 years) referred for diagnostic coronary angiography. Pantomography X-rays and coronary angiograms of the participants were scored blindly by single observers, a dentist and a radiologist respectively. The median pantomography score was 3.0 in male individuals belonging to the highest tertile of coronary atheromatosis score, as compared with 0.0 among the rest of the male participants (P = 0.003). The association between dental infections and severe coronary atheromatosis in males remained significant after adjusting for the effect of age, blood lipids, body mass index, hypertension, smoking and social class. No association between dental infections and coronary atheromatosis was observed in the small number of females studied. This observation supports the proposal that bacterial infections play a role in the pathogenesis of coronary atherosclerosis.

Three cases of displaced stress fracture of the femoral shaft are reported. All patients were young conscripts. Before displacement, the patients had suffered from knee and distal femoral pains for 2-6 weeks. All fractures were located at the border of the middle and distal third of the femoral shaft and had a short oblique form. Plating was performed in two and intramedullary nailing in one case. A fast bony union into a good position was achieved in all cases. Scintigraphy is indicated for an early diagnosis, which enables conservative treatment and prevention of the fracture displacement.

Transcutaneous oxygen tension measurement is an established method for monitoring immediate drug actions. The effects of prostacyclins in advanced limb ischaemia are controversial. To evaluate the immediate effects of epoprostenol infusion (10 ng/kg/min) on forefoot circulation, ten patients with distal ischaemia lesions were evaluated. During infusions systemic blood pressure was lowered, toe temperature elevated but transcutaneous oxygen tension was not changed. These results suggest a vasodilating action of the epoprostenol but contradict immediate positive effects on skin oxygenation.

Known risk factors for coronary heart disease do not explain all of the clinical and epidemiological features of the disease. To examine the role of chronic bacterial infections as risk factors for the disease the association between poor dental health and acute myocardial infarction was investigated in two separate case-control studies of a total of 100 patients with acute myocardial infarction and 102 controls selected from the community at random. Dental health was graded by using two indexes, one of which was assessed blind. Based on these indexes dental health was significantly worse in patients with acute myocardial infarction than in controls. The association remained valid after adjustment for age, social class, smoking, serum lipid concentrations, and the presence of diabetes. Further prospective studies are required in different populations to confirm the association and to elucidate its nature.