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author:("Kannus, pakka")
1.  Pertrochanteric fracture of the femur in the Finnish National Hospital Discharge Register: validity of procedural coding, external cause for injury and diagnosis 
Background
Hospital discharge data is routinely collected in Finland and it is an invaluable source of information when assessing injury epidemiology as well as treatment. The database can be used when planning injury prevention and redirecting resources of the health care system. Most recently our hospital discharge register has been used to assess the incidence of surgical treatment of common fractures. This study was aimed to evaluate the coverage and accuracy of the Finnish National Hospital Discharge Register (NHDR) focusing on hip fractures. In other words, patients hospitalized for a pertrochanteric hip fracture were used to assess the validity of the NHDR.
Methods
The validity of the NHDR was assessed by comparing the data in hospital discharge register with the original patient records and radiographs in three separate hospitals; Tampere University Hospital, Hatanpää City Hospital of Tampere, and the Central Hospital of Kanta-Häme. The study analysis included 741 patients hospitalized due to pertrochanteric hip fracture between 1st January 2008 and 31st December 2010.
Results
The diagnosis was correctly placed on 96% (95% CI: 94 to 97%) of the 741 patients when radiographs were used as golden standard. The procedural coding had coverage of 98% (95% CI: 96 to 98%) and an accuracy of 88% (95% CI: 85 to 90%). The coverage of the external cause for injury was found to be 95% (95% CI: 94 to 97%) with an accuracy of 90% (95% CI: 87 to 92%).
Conclusions
Our results show that the validity of the Finnish NHDR is excellent as determined by accuracy of diagnosis and both accuracy and coverage of procedural coding and external cause for injury. The database can be used to assess injury epidemiology and changes in surgical treatment protocols.
doi:10.1186/1471-2474-15-98
PMCID: PMC4026595  PMID: 24655318
2.  Double-bundle Anterior Cruciate Ligament reconstruction: a review of literature 
International Orthopaedics  2012;37(2):227-232.
Purpose
Anterior cruciate ligament (ACL) reconstruction has been under intensive discussion and debate, although the anatomy of this ligament was resolved thoroughly almost 200 years ago. The ACL consist of two bundles, anteromedial (AM) and posterolateral (PL). The conventional single-bundle method reconstructs the AM bundle only, while the modern double-bundle technique recreates both bundles for their anatomical sites.
Methods
An English language literature search was undertaken over the years 2000–2012 for ACL reconstruction, double-bundle versus single bundle technique. The search found 14 RCTs and two meta-analyses published to date.
Results
Two of the 14 studies (14 %) showed no difference between the two reconstruction methods while the remaining majority (12 trials, 86 %) concluded that the DB technique was better than the SB method. After the DB reconstruction, rotational stability of the knee was better in seven studies (50 %) and anteroposterior stability in six (43 %). No study spoke for the single-bundle technique. In addition, with the double-bundle technique knee scores were reported to be better in five (36 %) studies, and three trials (21 %) revealed less reoperations in the double-bundle group.
Conclusions
The double-bundle ACL reconstruction technique was reported to have better or at least the same results as the conventional single-bundle method—even at a five-year follow-up. However, the majority of these studies had a rather short follow-up, and thus, longer studies are needed to confirm the true long-term results of ACL surgery. Long follow-up periods are also needed to find out whether double-bundle ACL reconstruction can eventually prevent knee osteoarthritis.
doi:10.1007/s00264-012-1680-9
PMCID: PMC3560901  PMID: 23073927
3.  Effects of High-Impact Training and Detraining on Femoral Neck Structure in Premenopausal Women: A Hip Structural Analysis of an 18-Month Randomized Controlled Exercise Intervention with 3.5-Year Follow-Up 
Physiotherapy Canada  2012;64(1):98-105.
ABSTRACT
Purpose: This study evaluated the training effects of an 18-month exercise intervention and subsequent 3.5-year follow-up on femoral neck structure in premenopausal women. Methods: Of 98 women who participated in this randomized controlled study, 84 (39 trainees and 45 controls) completed the 18-month intervention. At both 18 months and 3.5 years, dual-energy X-ray absorptiometry data on 22 trainees and 22 control participants (ages 35–45 y) were available for hip structural analysis. The section modulus (Z), cross-sectional area (CSA), and subperiosteal width at the femoral neck were analyzed. Lower-leg explosive power and estimated maximal oxygen uptake (Vo2max) were assessed by vertical countermovement jump and standardized 2 km walking test, respectively. Progressive supervised high-impact exercises were done three times per week for 18 months. Results: Significant between-group differences in favour of trainees were observed after the 18-month intervention in Z (3.2%, p=0.047) and CSA (2.8%, p=0.043). At the 3.5-year follow-up point, the exercise-induced benefits in Z and CSA had diminished and were statistically insignificant. A between-group difference in favour of trainees was observed in lower-limb power after intervention (4.2%, p=0.002) and at 3.5-year follow-up (5.1%, p=0.003). A similar difference was seen in estimated Vo2max (5.6% after intervention, p=0.002, and 4.6% at 3.5-y follow-up, p=0.005). Conclusion: The 18-month high-impact exercise intervention strengthened the femoral neck in premenopausal women by enhancing its structural properties; however, this benefit was not maintained at 3.5-year follow-up. In contrast, the exercise benefits on physical performance continued to be maintained 3.5 years after intervention.
doi:10.3138/ptc.2010-37
PMCID: PMC3280715  PMID: 23277691
bone and bones; bone mineral density; exercise; osteoporosis; women; exercice; femmes; force osseuse; ostéoporose; résistance; structure osseuse
4.  Trends in the surgical treatment of proximal humeral fractures – a nationwide 23-year study in Finland 
Background
Proximal humeral fractures are common osteoporotic fractures. Most proximal humeral fractures are treated non-surgically, although surgical treatment has gained popularity. The purpose of this study was to determine changes in the surgical treatment of proximal humeral fractures in Finland between 1987 and 2009.
Methods
The study covered the entire adult (>19 y) population in Finland over the 23-year period from 1st of January 1987 to 31st of December 2009. We assessed the number and incidence of surgically treated proximal humeral fractures in each year of observation and recorded the type of surgery used. The cohort study was based on data from Finnish National Hospital Discharge Register.
Results
During the 23-year study period, a total of 10,560 surgical operations for proximal humeral fractures were performed in Finland. The overall incidence of these operations nearly quadrupled between 1987 and 2009. After the year 2002, the number of patients treated with plating increased.
Conclusion
An increase in the incidence of the surgical treatment of proximal humeral fractures was seen in Finland in 1987–2009. Fracture plating became increasingly popular since 2002. As optimal indications for each surgical treatment modality in the treatment of proximal humeral fractures are not known, critical evaluation of each individual treatment method is needed.
doi:10.1186/1471-2474-13-261
PMCID: PMC3537526  PMID: 23273247
5.  Study protocol for prevention of falls: A randomized controlled trial of effects of vitamin D and exercise on falls prevention 
BMC Geriatrics  2012;12:12.
Background
Falls are the leading cause of unintentional injury and injury-related death among older people. In addition to physical activity, vitamin D also may affect balance and neuromuscular function. Low serum 25-hydroksivitamin D level increases the risk of bone loss, falls and fractures. Thus, an appropriate exercise program and sufficient vitamin D intake may significantly improve not only functional balance, but also balance confidence. Balance represents a complex motor skill determined by reaction time, muscle strength, and speed and coordination of movement.
Methods/Design
A 2-year randomized double-blind placebo-controlled vitamin D and open exercise trial of 409 home-dwelling women 70 to 80 years of age comprising four study arms: 1) exercise + vitamin D (800 IU/d), 2) exercise + placebo, 3) no exercise + vitamin D (800 IU/d), 4) no exercise + placebo. In addition to monthly fall diaries, general health status, life style, bone health, physical functioning, and vitamin D metabolism will be assessed. The primary outcomes are the rate of falls and fall-related injuries. Secondary outcomes include changes in neuromuscular functioning (e.g. body balance, muscle strength), ADL- and mobility functions, bone density and structure, cardiovascular risk factors, quality of life and fear of falling.
Discussion
The successful completion of this trial will provide evidence on the effectiveness of exercise and vitamin D for falls reduction.
Trial Registration
ClinicalTrial.gov -register (NCT00986466).
doi:10.1186/1471-2318-12-12
PMCID: PMC3342151  PMID: 22448872
Exercise; Falls; Physical functioning; Vitamin D; Mobility function; Neuromuscular functioning; Quality of life
6.  Neuromuscular training with injury prevention counselling to decrease the risk of acute musculoskeletal injury in young men during military service: a population-based, randomised study 
BMC Medicine  2011;9:35.
Background
The rapidly increasing number of activity-induced musculoskeletal injuries among adolescents and young adults is currently a true public health burden. The objective of this study was to investigate whether a neuromuscular training programme with injury prevention counselling is effective in preventing acute musculoskeletal injuries in young men during military service.
Methods
The trial design was a population-based, randomised study. Two successive cohorts of male conscripts in four companies of one brigade in the Finnish Defence Forces were first followed prospectively for one 6-month term to determine the baseline incidence of injury. After this period, two new successive cohorts in the same four companies were randomised into two groups and followed prospectively for 6 months. Military service is compulsory for about 90% of 19-year-old Finnish men annually, who comprised the cohort in this study. This randomised, controlled trial included 968 conscripts comprising 501 conscripts in the intervention group and 467 conscripts in the control group. A neuromuscular training programme was used to enhance conscripts' motor skills and body control, and an educational injury prevention programme was used to increase knowledge and awareness of acute musculoskeletal injuries. The main outcome measures were acute injuries of the lower and upper limbs.
Results
In the intervention groups, the risk for acute ankle injury decreased significantly compared to control groups (adjusted hazards ratio (HR) = 0.34, 95% confidence interval (95% CI) = 0.15 to 0.78, P = 0.011). This risk decline was observed in conscripts with low as well as moderate to high baseline fitness levels. In the latter group of conscripts, the risk of upper-extremity injuries also decreased significantly (adjusted HR = 0.37, 95% CI 0.14 to 0.99, P = 0.047). In addition, the intervention groups tended to have less time loss due to injuries (adjusted HR = 0.55, 95% CI 0.29 to 1.04).
Conclusions
A neuromuscular training and injury prevention counselling programme was effective in preventing acute ankle and upper-extremity injuries in young male army conscripts. A similar programme could be useful for all young individuals by initiating a regular exercise routine.
Trial registration
ClinicalTrials.gov identifier number NCT00595816.
doi:10.1186/1741-7015-9-35
PMCID: PMC3084158  PMID: 21481230
7.  Shifting the focus in fracture prevention from osteoporosis to falls 
BMJ : British Medical Journal  2008;336(7636):124-126.
Preventing fractures in older people is important. But Teppo Järvinen and colleagues believe that we should be putting our efforts into stopping falls not treating low bone mineral density
doi:10.1136/bmj.39428.470752.AD
PMCID: PMC2206310  PMID: 18202065
8.  Targeted exercise against osteoporosis: A systematic review and meta-analysis for optimising bone strength throughout life 
BMC Medicine  2010;8:47.
Background
Exercise is widely recommended to reduce osteoporosis, falls and related fragility fractures, but its effect on whole bone strength has remained inconclusive. The primary purpose of this systematic review and meta-analysis was to evaluate the effects of long-term supervised exercise (≥6 months) on estimates of lower-extremity bone strength from childhood to older age.
Methods
We searched four databases (PubMed, Sport Discus, Physical Education Index, and Embase) up to October 2009 and included 10 randomised controlled trials (RCTs) that assessed the effects of exercise training on whole bone strength. We analysed the results by age groups (childhood, adolescence, and young and older adulthood) and compared the changes to habitually active or sedentary controls. To calculate standardized mean differences (SMD; effect size), we used the follow-up values of bone strength measures adjusted for baseline bone values. An inverse variance-weighted random-effects model was used to pool the results across studies.
Results
Our quality analysis revealed that exercise regimens were heterogeneous; some trials were short in duration and small in sample size, and the weekly training doses varied considerably between trials. We found a small and significant exercise effect among pre- and early pubertal boys [SMD, effect size, 0.17 (95% CI, 0.02-0.32)], but not among pubertal girls [-0.01 (-0.18 to 0.17)], adolescent boys [0.10 (-0.75 to 0.95)], adolescent girls [0.21 (-0.53 to 0.97)], premenopausal women [0.00 (-0.43 to 0.44)] or postmenopausal women [0.00 (-0.15 to 0.15)]. Evidence based on per-protocol analyses of individual trials in children and adolescents indicated that programmes incorporating regular weight-bearing exercise can result in 1% to8% improvements in bone strength at the loaded skeletal sites. In premenopausal women with high exercise compliance, improvements ranging from 0.5% to 2.5% have been reported.
Conclusions
The findings from our meta-analysis of RCTs indicate that exercise can significantly enhance bone strength at loaded sites in children but not in adults. Since few RCTs were conducted to investigate exercise effects on bone strength, there is still a need for further well-designed, long-term RCTs with adequate sample sizes to quantify the effects of exercise on whole bone strength and its structural determinants throughout life.
doi:10.1186/1741-7015-8-47
PMCID: PMC2918523  PMID: 20663158
9.  Is Childhood Obesity Associated with Bone Density and Strength in Adulthood? 
Journal of Osteoporosis  2010;2010:904806.
Associations between childhood obesity and adult bone traits were assessed among 62 obese premenopausal women, of which 12 had been obese since childhood (ObC), and 50 had gained excess weight in adulthood (ObA). Body composition and bone mineral content (BMC) of the total body, spine, and proximal femur were assessed with DXA. Total cross-sectional area and cortical (diaphyseal CoD) and trabecular (epiphyseal TrD) bone density of the radius and tibia were measured with pQCT. Compared to ObA-group, ObC-group was 5.2 cm taller having 2.5 and 3.5 kg more lean and fat mass, respectively. Depending on the statistical adjustment, ObC-group had 5–10% greater TrD both in tibia and in radius. The remaining bone traits did not significantly differ between the groups. Current preliminary observations bring up an interesting question whether childhood obesity can result in denser trabecular bone in adulthood. However, prudence must be exercised in the statistical adjustment.
doi:10.4061/2010/904806
PMCID: PMC2957246  PMID: 20981339
10.  Correction: Pathogenesis of Age-Related Osteoporosis: Impaired Mechano-Responsiveness of Bone Is Not the Culprit 
PLoS ONE  2008;3(8):10.1371/annotation/5d8eaa9e-b4b2-4b90-8fa6-242ba94fac5e.
doi:10.1371/annotation/5d8eaa9e-b4b2-4b90-8fa6-242ba94fac5e
PMCID: PMC2655758
11.  Correction: Pathogenesis of Age-Related Osteoporosis: Impaired Mechano-Responsiveness of Bone Is Not the Culprit 
PLoS ONE  2008;3(8):10.1371/annotation/6083a0e9-04e7-46dc-bb6d-9de65579d2bb.
doi:10.1371/annotation/6083a0e9-04e7-46dc-bb6d-9de65579d2bb
PMCID: PMC2655757
12.  Neuromuscular training and the risk of leg injuries in female floorball players: cluster randomised controlled study 
BMJ : British Medical Journal  2008;337(7661):96-99.
Objective To investigate whether a neuromuscular training programme is effective in preventing non-contact leg injuries in female floorball players.
Design Cluster randomised controlled study.
Setting 28 top level female floorball teams in Finland.
Participants 457 players (mean age 24 years)—256 (14 teams) in the intervention group and 201 (14 teams) in the control group—followedup for one league season (six months).
Intervention A neuromuscular training programme to enhance players’ motor skills and body control, as well as to activate and prepare their neuromuscular system for sports specific manoeuvres.
Main outcome measure Acute non-contact injuries of the legs.
Results During the season, 72 acute non-contact leg injuries occurred, 20 in the intervention group and 52 in the control group. The injury incidence per 1000 hours playing and practise in the intervention group was 0.65 (95% confidence interval 0.37 to 1.13) and in the control group was 2.08 (1.58 to 2.72). The risk of non-contact leg injury was 66% lower (adjusted incidence rate ratio 0.34, 95% confidence interval 0.20 to 0.57) in the intervention group.
Conclusion A neuromuscular training programme was effective in preventing acute non-contact injuries of the legs in female floorball players. Neuromuscular training can be recommended in the weekly training of these athletes.
Trial registration Current Controlled Trials ISRCTN26550281.
doi:10.1136/bmj.a295
PMCID: PMC2453298  PMID: 18595903
13.  Pathogenesis of Age-Related Osteoporosis: Impaired Mechano-Responsiveness of Bone Is Not the Culprit 
PLoS ONE  2008;3(7):e2540.
Background
According to prevailing understanding, skeletal mechano-responsiveness declines with age and this apparent failure of the mechano-sensory feedback system has been attributed to the gradual bone loss with aging (age-related osteoporosis). The objective of this study was to evaluate whether the capacity of senescent skeleton to respond to increased loading is indeed reduced as compared to young mature skeleton.
Methods and Findings
108 male and 101 female rats were randomly assigned into Exercise and Control groups. Exercise groups were subjected to treadmill training either at peak bone mass between 47–61 weeks of age (Mature) or at senescence between 75–102 weeks of age (Senescent). After the training intervention, femoral necks and diaphysis were evaluated with peripheral quantitative computed tomography (pQCT) and mechanical testing; the proximal tibia was assessed with microcomputed tomography (μCT). The μCT analysis revealed that the senescent bone tissue was structurally deteriorated compared to the mature bone tissue, confirming the existence of age-related osteoporosis. As regards the mechano-responsiveness, the used loading resulted in only marginal increases in the bones of the mature animals, while significant exercise-induced increases were observed virtually in all bone traits among the senescent rats.
Conclusion
The bones of senescent rats displayed a clear ability to respond to an exercise regimen that failed to initiate an adaptive response in mature animals. Thus, our observations suggest that the pathogenesis of age-related osteoporosis is not attributable to impaired mechano-responsiveness of aging skeleton. It also seems that strengthening of even senescent bones is possible – naturally provided that safe and efficient training methods can be developed for the oldest old.
doi:10.1371/journal.pone.0002540
PMCID: PMC2481275  PMID: 18648530
14.  Adolescents' health and health behaviour as predictors of injury death. A prospective cohort follow-up of 652,530 person-years 
BMC Public Health  2008;8:90.
Background
Injuries represent an important cause of mortality among young adults. Longitudinal studies on risk factors are scarce. We studied associations between adolescents' perceived health and health behaviour and injury death.
Methods
A prospective cohort of 57,407 Finns aged 14 to 18 years was followed for an average of 11.4 years. The end-point of study was injury death or termination of follow-up in 2001. The relationships of eight health and health behaviour characteristics with injury death were studied with adjusted Cox's proportional hazard model.
Results
We identified 298 (0.5%) injury deaths, 232 (0.9%) in men and 66 (0.2%) in women. The mean age at death was 23.8 years. In the models adjusted for age, sex and socioeconomic background, the strongest risk factors for injury death were recurring drunkenness (HR 2.1; 95% CI: 1.4–3.1) and daily smoking (HR 1.7; 95% CI: 1.3–2.2). Poor health did not predict injury death. Unintentional and intentional injury deaths had similar health and health behavioural risk factors.
Conclusion
Health compromising behaviour adopted at adolescence has a clear impact on the risk of injury death in adulthood independent from socioeconomic background. On the other hand, poor health as such is not a significant predictor of injury death. Promotion of healthy lifestyle among adolescents as part of public health programmes would seem an appropriate way to contribute to adolescent injury prevention.
doi:10.1186/1471-2458-8-90
PMCID: PMC2292710  PMID: 18366651
15.  Neuromuscular training and the risk of leg injuries in female floorball players: cluster randomised controlled study 
Objective To investigate whether a neuromuscular training programme is effective in preventing non-contact leg injuries in female floorball players.
Design Cluster randomised controlled study.
Setting 28 top level female floorball teams in Finland.
Participants 457 players (mean age 24 years)—256 (14 teams) in the intervention group and 201 (14 teams) in the control group—followedup for one league season (six months).
Intervention A neuromuscular training programme to enhance players’ motor skills and body control, as well as to activate and prepare their neuromuscular system for sports specific manoeuvres.
Main outcome measure Acute non-contact injuries of the legs.
Results During the season, 72 acute non-contact leg injuries occurred, 20 in the intervention group and 52 in the control group. The injury incidence per 1000 hours playing and practise in the intervention group was 0.65 (95% confidence interval 0.37 to 1.13) and in the control group was 2.08 (1.58 to 2.72). The risk of non-contact leg injury was 66% lower (adjusted incidence rate ratio 0.34, 95% confidence interval 0.20 to 0.57) in the intervention group.
Conclusion A neuromuscular training programme was effective in preventing acute non-contact injuries of the legs in female floorball players. Neuromuscular training can be recommended in the weekly training of these athletes.
Trial registration Current Controlled Trials ISRCTN26550281.
doi:10.1136/bmj.a295
PMCID: PMC2453298  PMID: 18595903
16.  Physical Activity Reduces the Risk of Fragility Fracture 
PLoS Medicine  2007;4(6):e222.
The authors discuss a new study, with a 35 year follow up, showing that exercise reduces the risk of fragility fractures in men.
doi:10.1371/journal.pmed.0040222
PMCID: PMC1892042  PMID: 17579512
17.  Bone Quality: An Empty Term 
PLoS Medicine  2007;4(3):e27.
doi:10.1371/journal.pmed.0040027
PMCID: PMC1808066  PMID: 17341126
19.  Genetic factors and osteoporotic fractures in elderly people: prospective 25 year follow up of a nationwide cohort of elderly Finnish twins 
BMJ : British Medical Journal  1999;319(7221):1334-1337.
Objective
To determine whether genetic factors partly explain variation in risk of osteoporotic fracture, the true end point of the osteoporosis problem.
Design
Prospective 25 year follow up of a nationwide cohort of elderly Finnish twins.
Setting
The Finnish twin cohort and the national hospital discharge register, covering the entire 5 million population of Finland.
Subjects
All same sex twin pairs born before 1946. The cohort contained 2308 monozygotic and 5241 dizygotic twin pairs (15 098 people) at the beginning of follow up.
Main
outcome measure The number and concordance of osteoporotic fractures in the twin pairs, 1972-96.
Results
786 cohort members sustained an osteoporotic fracture. In women, the pairwise concordance rate for fracture (that is, the relative number of twin pairs in whom the fracture affected both twins in a pair) was 9.5% (95% confidence interval 5.3% to 15.5%) in monozygotic pairs and 7.9% (5.2% to 11.4%) in dizygotic pairs. In men, the figures were 9.9% (4.4% to 18.5%) and 2.3% (0.6% to 5.7%).
Conclusions
Susceptibility to osteoporotic fractures in elderly Finns is not strongly influenced by genetic factors, especially in elderly women. The traditional strategy for prevention of osteoporotic fractures—that is, increasing peak bone mass and preventing age related bone loss—should be changed to include new elements such as prevention of falls and protection of the critical anatomical sites of the body when a fall occurs.
Key messagesGenetic factors have a substantial role in explaining age specific variation in bone mass and density, but no previous study has directly evaluated whether they have a role in the variation of risk of osteoporotic fracture, the true end point of the entire osteoporosis problemGenetic factors are not strongly related to likelihood of osteoporotic fracture, particularly in elderly womenFor this reason, the traditional prevention strategy of osteoporotic fractures—increasing peak bone mass and preventing age related bone loss—could include new additional elements, such as prevention of falls in elderly people and protection of the critical anatomical sites of the body when a fall occurs
PMCID: PMC28279  PMID: 10567136

Results 1-20 (20)