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AIMS: Recent studies of nonoperatively treated displaced midshaft clavicular fractures have shown a high incidence of nonunion and unsatisfactory functional outcome. Some studies have shown superior functional results and higher rates of healing following operative treatment. The aim of this study was to compare the outcome in these patients after nonoperative management with those treated with fixation. PATIENTS AND METHODS: In a multicentre, parallel randomized controlled trial, 146 adult patients with an acute displaced fracture of the midthird of the clavicle were randomized to either nonoperative treatment with a sling (71, 55 men and 16 women with a mean age of 39 years, 18 to 60) or fixation with a pre-contoured plate and locking screws (75, 64 men and 11 women with a mean age of 40 years, 18 to 60). Outcome was assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) Score, the Constant Score, and radiographical evidence of union. Patients were followed for one year. RESULTS: A total of 60 patients in the nonoperative group and 64 in the operative group completed one-year follow-up. At three months' follow-up, both the median DASH (1.7 vs 8.3) and median Constant scores (97 vs 90) were significantly better in the operated group (both p = 0.02). After six months and one year, there was no difference in the median DASH or Constant scores. The rate of nonunion was lower in the operative group (2 vs 11 patients, p < 0.02). Nine patients in the nonoperative group underwent surgery for nonunion. The plate was subsequently removed in 16 patients (25%). One patient had a new fracture after removal of the plate and one underwent revision surgery for failure of fixation. CONCLUSION: Fixation of a displaced midshaft clavicular fracture using a pre-contoured plate and locking screws results in faster functional recovery and a higher rate of union compared with nonoperative management, but the function of the shoulder is equal after six months and at one year. Cite this article: Bone Joint J 2018;100-B:1385-91.

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This systematic review provides synthesised knowledge and guidance to health professionals on the experiences and perspectives of being diagnosed with osteoporosis from the patient's point of view. Using individuals' experiences and meanings can promote tailored and targeted information and guidance on osteoporosis, bone care and treatment at different stages of the osteoporosis trajectory. INTRODUCTION: To be diagnosed with osteoporosis with or without fragility fractures affects individuals differently. The aim of this review was firstly to aggregate existing qualitative evidence regarding an individual's experience of being diagnosed with osteoporosis at different stages, and secondly, to use a systematic approach to develop a conceptual understanding of central issues relevant for health professionals in order to provide support and guidance to patients/individuals. METHODS: This study used a systematic review methodology and methods for qualitative synthesis as recommended by Cochrane and integrated the findings of qualitative research from eight databases (Medline, PubMed, CINAHL, Embase, SweMed+, PsycINFO, ERIC, Web of Science) to July 2016. Selection and assessment were performed by three authors while four authors were involved in the analysis. Findings were cross-checked with the original article to ensure consistency with the individual's accounts. RESULTS: Our findings have revealed that individuals diagnosed with osteoporosis do not perceive osteoporosis as a biomedical trajectory but as a self-perceived continuum of severity and health. To be diagnosed with osteoporosis affects individuals differently depending on, for example, personal experience, pre-conceived notions of or knowledge about the disease, fragility fractures or pain. Hence, individuals will create a meaning of the diagnosis based on self-perceived fracture risk, self-perceived severity of osteoporosis and at the same time, self-perceived health. CONCLUSIONS: This meta-synthesis provides knowledge for health professionals on the experiences and perspectives of being diagnosed with osteoporosis from the patient's point of view. The experience, meaning and significance of osteoporosis must be taken into consideration and can be used to promote tailored and targeted information and guidance on osteoporosis, bone care and treatment at different stages of the osteoporosis trajectory.

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We investigated the adhesion of two functional groups to α-alumina as a model for the adsorption of organic molecules on clay minerals. Interactions between organic compounds and clay minerals play an important role in processes such as drinking water treatment, remediation of contaminated soil, oil recovery, and fabricating complicated nanomaterials, and there have been claims that organic compound-clay mineral interaction created the ordering that is necessary for the genesis of life. In many organisms, interaction between organic molecules and biominerals makes it possible to control the growth of bones, teeth, and shells. Adhesion of carboxylic acid, -COO(H), and pyridine, -C5H5N(H(+)), on the {0001} plane of α-alumina wafers has been investigated with atomic force microscopy (AFM) in chemical force mapping (CFM) mode. Both functional groups adhered to α-alumina in deionized water at pH < 5, and adhesion decreased as NaCl or CaCl2 concentration increased. X-ray photoelectron spectroscopy (XPS) showed that Na(+) and Ca(2+) adsorbed to the α-alumina surface at pH < 5, decreasing surface interaction with the carboxylic acid and pyridine groups. We interpret the results as evidence that the tips adhere to alumina through hydrogen bonding when only water is present. In solutions containing NaCl and CaCl2, cations are adsorbed but Cl(-) is not. When NaCl solutions are replaced by CaCl2, Ca(2+) replaces Na(+), but rinsing with ultrapure deionized water (pH 5.6) could not restore the original protonated surface. The results demonstrate that the alumina surface at pH 3 has a higher affinity for inorganic cations than for -COO(H) or -C5H5N(H(+)), in spite of the known positive surface charge of α-alumina {0001} wafers. These results demonstrate that solution salinity plays an important role in surface properties, controlling surface tension (i.e., contact angle) and adsorption affinity on α-alumina and, by analogy, on clay minerals.

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The dehydriding reaction of single-phase alpha- AlH3 was investigated by in situ microscopic observations combined with thermal and surface analyses. Before the dehydriding reaction, primary AlH3 particles of size 100 nm-1 microm were thought to be covered by an oxide layer with a thickness of less than 5 nm. Both the precipitation/grain-growth of metallic Al of size 1-50 nm and an increase in 'boundary space' were clearly observed inside the particles, while the morphologies of the particles covered by the layer did not change during the dehydriding reaction. This preliminary report provides fundamental information for a further study of AlH3 as a possible hydrogen storage material.

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We have detected the occurrence of hydrogen bonding involving an interstitial positive muon situated between hydrogen atoms of two independent alanate anions in sodium alanate (NaAlH4). Ti doping, which is known to dramatically improve the hydrogen cycling performance of NaAlH4, reduces the kinetic barrier of the transition of the muon from the muon-dialanate state to a mobile interstitial state. This observation strongly suggests that hydrogen bonding is the primary bottleneck for hydrogen release or uptake in sodium alanate, which might be common to other complex hydrides.

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Levetiracetam has recently been approved as an adjunctive medication for partial seizures and frequently will be added to phenytoin. The objective of this study was to determine the presence or absence of a pharmacokinetic drug interaction of levetiracetam with phenytoin. A stable isotope tracer technique using deuterium-labeled (D10) phenytoin and high-performance liquid chromatography with ultraviolet detection (rather than mass spectrometric detection) was employed. Tracer doses of D10-phenytoin were administered i.v. before and 12 weeks after adding levetiracetam to the regimen of 6 subjects on phenytoin monotherapy for epilepsy. Blood was collected for 96 hours after each infusion. The following pharmacokinetic parameters were determined for phenytoin: Cmax, Cmin, Cavo, AUC, CL, t 1/2, VD, and free (nonprotein bound) fraction. The ratio and the 90% confidence interval of the ratio of log-transformed mean values for phenytoin pharmacokinetic parameters before (denominator) and after (numerator) adding levetiracetam all fell within the range of 0.85 to 1.17 (two one-sided test). The authors conclude that the addition of levetiracetam did not bring about clinically important changes in phenytoin pharmacokinetic parameters and that it is not necessary to change the phenytoin dosing rate when levetiracetam is added to phenytoin.

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Several studies on operated ankle fractures have shown that immediate weight-bearing is recommendable. Consequently, we changed our postoperative standard regimen, from 3 weeks of non-weight-bearing followed by 3 weeks of weight-bearing, to full immediate weight-bearing in all 6 weeks. A below-knee walking cast was applied immediately after surgery. Between December 1995 and September 1996, we studied 62 patients (median age, 55 years; range 21-92 years; M/F, 24/38), with ankle fractures who attended our emergency department and were subsequently admitted for open reduction and internal fixation. We excluded patients with distal tibia fracture and patients under 18 years of age. Overall, our elderly population did not have complication rates higher than those reported in similar studies on younger patients. In 1 patient, we observed radiographic widening of the ankle joint, of about 3 mm, 6 weeks postoperatively. No patients required reoperation. Our study indicates that full immediate weight-bearing after open reduction and internal fixation is recommendable, even in an elderly population.

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Reinfusion of postoperative wound drainage blood has become an attractive alternative in primary total knee and hip arthroplasty. Quality of the drainage blood was studied with respect to content of extracellular bioactive substances and coagulation split products. Using the HandyVac ATS autotransfusion system, drainage blood was collected and reinfused within 6 hours postoperatively from 10 patients undergoing primary total knee arthroplasty. Blood samples were collected from the patients immediately after and 1 hour after opening of the tourniquet and after reinfusion of drainage blood. Samples were also collected from the drainage blood immediately before and at the end of reinfusion. The leukocyte-derived and platelet-derived bioactive substances histamine, eosinophil cationic protein (ECP), eosinophil protein X (EPX), myeloperoxidase (MPO), plasminogen activator inhibitor type 1 (PAI-1), and activated complement factor C3(C3a) and various coagulation factors and split products were analyzed in patient and drainage blood samples. None of the patients received additional predonated autologous blood or allogeneic blood components during the study period. Within 6 hours postoperatively, 250 to 1,000 mL drainage blood was collected and reinfused. Histamine, ECP, EPX, MPO, PAI-1, and C3a content was significantly increased in drainage blood immediately before and at the end of reinfusion. Reinfusion did not change the concentration of these substances in samples from the patients. Coagulation factors and various split products showed that drainage blood was defibrinated. Reinfusion of drainage blood did not change the coagulative capacity of the patients. Drainage blood appears to be defibrinated and contains various extracellular leukocyte-derived and platelet-derived bioactive substances. Reinfusion does not change the coagulative capacity or the concentration of bioactive substances of patients.

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Patients with rheumatoid arthritis are at greater risk of developing joint infections than any other group of patients. Diagnosis is often delayed because of the difficulties in distinguishing between a flare-up and a septic affection of the joint. A case of septic arthritis with multiple joint involvement and lethal outcome despite extensive antibiotic treatment and successive surgical procedures is presented. The patient developed osteomyelitis and multiple organ failure. In order to reduce morbidity and mortality from septic arthritis, early joint puncture and subsequent antibiotic treatment is essential.

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Rheumatoid arthritis has a prevalence of between 1% and 2%. The majority of patients face the prospect of surgical treatment of joints, that do not respond to medical treatment. With respect to the extensive development in joint surgery during the last decade, today's recommendations for surgical treatment of the individual joints are surveyed.

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Lesopitron, a 5-hydroxytryptamine 1A agonist, is a new potential anxiolytic of the azapirone class. It has greater potency in animal models of anxiety than buspirone, gepirone, or ipsapirone, and it lacks the antidopaminergic effects associated with buspirone. Lesopitron has been tolerated at single doses up to 50 mg and repeated dosages of 45 mg/day in healthy volunteers. Forty-two patients with generalized anxiety disorder (GAD) were enrolled in this double-blind bridging study to determine the safety and tolerability of fixed doses of lesopitron (20, 25, 30, 40, 45, 50, and 60 mg two times a day) over a 6 1/2-day inpatient administration period. Each of the seven panels included six patients (four drug/two placebo). One patient in the 25-mg, two-times-a-day panel voluntarily withdrew because of increased anxiety symptoms. One patient experienced severe orthostatic hypotension at 60 mg two times a day, and moderate to severe adverse events (dizziness, lightheadedness, nausea, headache) occurred in two other patients at this dosage. The most commonly reported adverse events in all the panels were headache, dizziness, and nausea. Lesopitron is rapidly absorbed in patients, having a time to maximum concentration (Tmax) ranging from 0.5 to 1 hour, and its elimination half-life ranged from 1.1 to 5.6 hours. Peak plasma concentrations showed high interindividual variability for lesopitron, but increased linearly with dose for the main metabolite, 5-hydroxylesopitron. We defined the maximum tolerated dose in GAD patients as 50 mg two times a day, twice as high as the highest dose tested in healthy volunteers.

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We present the results of a clinical and radiographic follow-up study of patients undergoing elbow synovectomies. Twenty-five elbows in 24 patients with rheumatoid arthritis were followed for a median period of 52 months (range 10-108) after operation. Nineteen (74%) stated they had improvement of pain and function. Two patients reported increased pain. Improvement of motion was noted, but this was not statistically significant. Radiographic classification showed statistically significant progressive changes. Three complications were noted, all without permanent sequels. Moderate elbow destruction can provide a good indication for elbow synovectomy in the treatment of patients suffering from rheumatoid arthritis.

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We compared biodegradable pins with standard Kirschner wires in the fixation of fractures, arthrodeses and osteotomies in the hand in a prospective, randomized study. Eleven patients were allocated to the biodegradable pin group and 12 to the Kirschner wire group. Age, gender, operative procedure and postoperative treatment did not differ in the two groups. All patients were evaluated after 6 months. No differences in time to union or complication rates were found, but the number of additional operative procedures in the Kirschner wire group significantly exceeded the number needed in the biodegradable pin group.

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By means of Kappa statistics, we calculated the inter- and intra-observer variation in the classification of fractures of the neck of the femur according to Garden's system. Radiographs of 96 consecutive patients were assessed independently by six observers who agreed on classification for only 14 fractures (15%). The level of agreement was poor for the overall classification (Kappa = 0.39). When reducing Garden's system into non-displaced (Stage I and II) and displaced fractures (Stage III and IV) the level of agreement became acceptable (Kappa = 0.68). However, problems remain in distinguishing Stage II and Stage III fractures, and further improvements in the classification system are necessary.

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Resection arthroplasty of the forefoot was performed in 30 patients (48 feet) with rheumatoid arthritis. A Keller/Clayton procedure yielded good results, whereas a less radical operation (Hybbinette) created poor results. Reoperation following failed Hybbinette operations was possible.

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Surgical synovectomy in the treatment of rheumatoid arthritis has been performed for more than a 100 years, and yet the definite indication has not been made clear. Synovectomy has a convincing, but mostly time-limited effect on pain and articular hydrops, but the radiological progression continues almost undisturbed. Histological evaluation of the regenerating synovial membrane has now shown a tendency towards reversing to baseline within about a year. The difficulties in evaluating the operation are caused by the lack of comparable randomized studies performed on large populations, treated in a double-blind fashion and examined in cooperation between surgeon and rheumatologist.

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State and provincial proportional mortality studies in the United States and Canada have found increased ratios of overall injury mortality among farmers, including occupational injuries and other unintentional injuries, such as those from motor vehicle crashes and fires, as well as suicides. In contrast, Scandinavian standardized mortality (morbidity) studies have found no increase in the injury fatality or morbidity ratios of farmers in comparison with the rest of the population. This study reviews the injury mortality of Iowa farmers for the years 1980-1988. Among white male farmers, we found an increased proportional mortality ratio for all injuries of 1.26 (95% confidence interval (CI) 1.21-1.31). In part, this was a result of the increased proportional mortality ratio for at-work injuries of 3.77 (95% CI 3.35-4.24), but there were also elevated proportional mortality ratios for such nonoccupational injuries as suicides, 1.20 (95% CI 1.09-1.32), motor vehicle crashes, 1.23 (95% CI 1.12-1.34), and electrocutions, 1.78 (95% CI 1.08-2.95). For younger farmers aged 20-64 years, we calculated standardized mortality ratios as well. The standardized mortality ratios were generally within 10% of the proportional mortality ratios, which suggests that the differences between North America and Scandinavia are not the result of methodological differences, but are more likely related to differences in environmental exposures and safety practices.

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In this retrospective study we reviewed the clinical charts for 82 patients who underwent lower limb amputation at our department during 1990 and 1991. Our results are compared with the literature, and different aspects of the treatment are discussed. Subsequently a model for future quality assurance is presented.

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To estimate the effect of removal of internal fixation after treatment of malleolar fractures on postoperatively presented complaints, we retrospectively evaluated 66 patients by their records and by personal questionnaires. Of all the patients, 89.4% had one or more complaints. These were typically soreness over implant and cicatrix, reduced movement of the ankle joint, and strain-related pain. About 75% of these patients reported improvement after removal. The AO mode of fixation, i.e., typically by lateral semitubular plating and transsyndesmotic screw and a medial screw or pins, and the Wiberg-Cedell mode, i.e., typically consisting of lateral single or double cerclage and staple and medial pinning, constituted the principal groupings of the patients. The two groups were comparable. In this series, we found significantly more complaints associated with the AO mode in the postoperative period. We conclude that removal of internal fixation after malleolar fractures is indicated when common types of complaints are presented.

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