Introduction: Lumbar Total Disc Replacement (TDR) is an accepted treatment for recalcitrant Chronic Discogenic Low Back Pain. However, no studies have compared Lumbar TDR to non-operative intervention. The aim of this study was to investigate the two-year outcomes for con-current cohorts of chronic discogenic low back pain patients undergoing either Lumbar TDR or novel non-operative care. Methods: Data for the TDR cohort was from prospectively collected data of patients who had undergone Prodisc II lumbar TDR during August 2003 to December 2005. Two-year data for the non-operative cohort was collected prospectively from 880 sequential patients who underwent non-operative intervention between January to December 2005 and who met the inclusion and exclusion criteria. Inclusion criteria: age > 20 and < 65, single/two level disc disease, low back pain > 6 months, had failed non-operative intervention. Exclusion criteria were: previous lumbar surgery, listhesis, facet disease, osteoporosis, pregnancy, red flag conditions, or poor command of English. Additional non-operative inclusion criteria were: attended a minimum of 3 non-operative sessions, completed the entry questionnaire. Novel non-operative care consisted of a cognition-driven motor relearning intervention, aimed at altering provocative movements and postures and reintegrating these alterations into daily life. Manual therapy and spinal injections were used as an adjunct where needed. Pre-treatment and two-year follow-up data for the following outcomes were collated from a modified NASS questionnaire: back/leg pain, activity limitation, and global perceived improvement. Data was expressed as mean difference with 95% confidence intervals for the difference between the means. Student-t test and paired student-t test were used to assess between group and within group differences. Results: 16 patients (9 males) were identified in the lumbar TDR cohort with median age 43 years (29–57) and median duration of symptoms of 3.5 years (0.5–24). 16 patients (9 males) were also identified in the non-operative cohort with median age of 42 years (24–61) and median duration of symptoms of 2.5 years (0.5–24). There were no cross-overs, however one patient in the TDR cohort had previously undergone the non-operative care regime. There were no significant pre-treatment differences observed in age, sex, duration of symptoms and back pain intensity between cohorts. However, significant pre-treatment differences were observed with 25% greater leg pain and 25% greater activity limitation score in the TDR cohort when compared to the non-operative cohort. Following Lumbar TDR the mean differences at two years for back pain, leg pain and activity limitation favoured improvements of 3.6(2 to 5.1) and 3.4(1.8 to 4.9) and 30.5%(19.2–41.8) respectively when compared to pre-treatment. Similar improvements were observed for the non-operative cohort with 5.0(3.7–6.3), 2.8 (0.7–5.0) and 20.9%(9.4–32.4) for back pain, leg pain and activity limitation respectively. 71% of Lumbar TDR patients and 67% of Non-operative patients reported their relief of symptoms as exceeding 60% at the two-year follow-up. Discussion: The data suggests that prior to treatment, patients undergoing lumbar TDR were worse off in activity limitation and leg pain than the non-operative cohort. However, improvements in back pain, leg pain, and activity limitation are clinically significant at two-year follow-up with either Prodisc II-L TDR or novel non-operative care for chronic discogenic low back pain patients. Clinically, it may be reasonable to offer patients with lesser leg pain intensity and activity limitation ongoing non-operative care. This level 3 evidence needs to be supported with more case cohorts or an otherwise ethically difficult to conduct RCT

Purpose. Displaced midshaft clavicular fractures are a common injury with a high occurrence rate in young, active individuals. Non-operative care has traditionally been the standard of care for such fractures, but more recent studies have suggested benefits following primary operative fixation. The purpose of this study was to review the literature on displaced midshaft clavicle fractures, identify randomized controlled trials of operative versus non-operative treatment, and pool the functional outcome and complication rates (including nonunion and symptomatic malunion), to arrive at summary estimates of these outcomes. Method. A systematic review of the literature was performed to identify studies of randomized controlled trials comparing operative versus non-operative care for displaced midshaft clavicle fractures. Meeting abstracts were also searched and included in this study. Results. Six randomized controlled trials (n=421 patients, mean Detsky score= 15.2) were identified and included. The nonunion rate was higher in the non-operative group (28/207) then it was in patients treated operatively (3/214) (p<0.001). The rate of symptomatic malunion was higher in the non-operative group (15/207) than the operative group (0/214) (p<0.001). The total complication rate was 71 complications in 214 operative cases (33%), and 93 complications in 207 non-operative cases (45%)(p=0.016). The Constant Shoulder scores (CS) and Disability of the Arm, Shoulder and Hand (DASH) scores showed marginally improved (mean 4.1 point increase in CS at one year, mean 5.8 point decrease in DASH at one year) functional values in the operative group: this difference was especially marked in the early post operative period. Conclusion. Operative treatment provided lower complication rates (especially nonunion and symptomatic malunion) and an earlier functional return compared to non-operative treatment. However, there is little evidence at present to show that the long term effects of operative intervention are significantly superior to non-operative care

Objectives

To explore whether orthopaedic surgeons have adopted the Proximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial results routinely into clinical practice.

Abstract. Objective. Meta-analysis of clinical trials highlights that non-operative management of degenerative knee meniscal tears is as effective as surgical management. Surgical guidelines though support arthroscopic partial meniscectomy which remains common in NHS practice. Physiotherapists are playing an increasing role in triage of such patients though it is unclear how this influences clinical management and patient outcomes. Methods. A 1-year cohort (July 2019–June 2020) of patients presenting with MRI confirmed degenerative meniscal tears to a regional orthopaedic referral centre (3× ESP physiotherapists) was identified. Initial clinical management was obtained from medical records alongside subsequent secondary care management and routinely collected outcome scores in the following 2-years. Management options included referral for surgery, conservative (steroid injection and rehabilitation), and no active treatment. Outcome scores collected at 1- and 2-years included the Forgotten Joint Score-12 (FJS-12) questionnaire and 0–10 numerical rating scales for worst and average pain. Treatment allocation is presented as absolute and proportional figures. Change in outcomes across the cohort was evaluated with repeated measures ANOVA, with Bonferroni correction for multiple testing, and post-hoc Tukey pair-wise comparisons. As treatment decision is discrete, no direct contrast is made between outcomes of differing interventions but additional explorative outcome change over time evaluated by group. Significance was accepted at p=0.05 and effect size as per Cohen's values. Results. 81 patients, 50 (61.7%) male, mean age 46.5 years (SD13.13) presented in the study timeframe. 32 (40.3%) received conservative management and 49 (59.7%) were listed for surgery. Six (18.8%) of the 32 underwent subsequent surgery and nine of the 49 (18.4%) patients switched from planned surgery to receiving non-operative care. Two post-operative complications were noted, one cerebrovascular accident and one deep vein thrombosis. The cohort improved over the course of 2-years in all outcome measures with improved mean FJS-12 (34.36 points), mean worst pain (3.74 points) average pain (2.42 points) scores. Overall change (all patients) was statistically significant for all outcomes (p<0.001), with sequential year-on-year change also significant (p<0.001). Effect size of these changes were large with all Cohen-d values over 1. Controlling for age and BMI, males reported superior change in FJS-12 (p=0.04) but worse pain outcomes (p<0.03). Further explorative analysis highlighted positive outcomes across all surgical, conservative and no active treatment groups (p<0.05). The 15 (18%) patients that switched between surgical and non-surgical management also reported positive outcome scores (p<0.05). Conclusion(s). In a regional specialist physiotherapy-led soft tissue knee clinic around 60% of degenerative meniscal tears assessed were referred for surgery. Over 2-years, surgical, non-operative and no treatment management approaches in this cohort all resulted in clinical improvement suggesting that no single strategy is effective in directly treating the meniscal pathology, and that perhaps none do. Clinical intervention rather is directed at individual symptom management based on clinical preferences. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

This prospective, randomized, controlled trial compares patient outcome after non-operative care versus open reduction and tunneled suspension device fixation (ORTSD) for grade III or IV acromioclavicular joint disruptions. Sixty patients aged between sixteen and thirty-five years with an acute grade III or IV AC joint disruption were randomized to receive ORTSD fixation or non-operative treatment. Functional assessment was conducted at six weeks, three months, six months, and one year using the Disabilities of the Arm, Shoulder and Hands (DASH), Oxford Shoulder Scores (OSS) and Short Form (SF-12). Reduction was evaluated using radiographs. Complications were recorded, and an economic evaluation performed. There was no significant difference in DASH or OSS at one year between non-operative and ORTSD groups (DASH score, 4.67 versus 5.63; OSS, 45.72 versus 45.63). Patients undergoing surgery had inferior DASH scores at 6 weeks (p<0.01). Five patients who failed non-operative management subsequently received surgery. Overall cost of treatment was significantly greater after ORTSD fixation (£796.22 vs £3359.73 (p<0.01)). ORTSD fixation confers no functional benefit over non-operative treatment at one year. While patients managed non-operatively generally recover faster, a significant group remain dissatisfied following non-operative treatment requiring delayed surgical reconstruction

Greater trochanter fractures after total hip replacement have been reported in up to 5% of cases. The outcomes are generally poor. Treatment options include non-operative care or surgical treatment with cerclage wires or a claw plate. We present a simple tension band technique for acute fractures with a single bony fracture fragment. We have not used the technique for chronic or comminuted fractures. Technique: 2.5mm k-wires are passed through the fragment and anterior and posterior to the femoral implant. Eighteen-gauge wire is passed through a drill hole in the femur distal to the fracture and around the k-wires in a figure eight. The patient is kept 50% weightbearing with no active abduction for 4 weeks. In four cases the fracture has gone on to healing. Patients have had a negative Trendelenburg sign without peritrochanteric pain. The tension band technique is familiar to surgeons and has been reliable

To evaluate the cost-effectiveness of operative versus non-operative management of displaced intra-articular calcaneal fractures (DIACFS), a model was constructed based on a randomized clinical trial. Model outputs were costs and quality-adjusted life years (QALYs). When a societal perspective was taken (i.e. productivity losses were included), operative management was less costly and more effective than non-operative care. Sensitivity analysis revealed that cost-effectiveness was highly dependent on the estimates of productivity losses. When productivity losses were excluded, the increase in cost of operative treatment was $2,700 for an incremental gain of .06 QALYs, giving an incremental cost-utility (CU) ratio of $44,000 per QALY gained. To evaluate the cost-effectiveness of operative versus non-operative management of displaced intra-articular calcaneal fractures (DIACFs). A decision tree was constructed to model the effect on costs and quality-adjusted life years (QALYs) of operative versus non-operative management for DIACFs. Complication rate, fusion rate, patient survival and utilities, and productivity losses were estimated from a recent prospective randomized control trial. Four-year costs were estimated from the center treating 73% of the patients in the trial. A societal perspective was used. Future costs and benefits were discounted at 5% and reported in 2002 Canadian Dollars. One-way and multi-way sensitivity analysis was performed on all variables using plausible ranges. When productivity losses were included, operative management was less costly ($13,000 saving) and had a gain of .06 QALYs (based on improvements in health related quality of life), making it the dominant strategy compared to non-operative treatment. The cost-effectiveness was most sensitive to the return to work estimates. When productivity losses were excluded, the increase in cost of operative treatment was $2,700 for a .06 QALY gain, giving an incremental cost-utility (CU) ratio of $44,000 per QALY gained. The treatment of the DIACF has long a source of uncertainty in orthopedic surgery. A recent prospective, randomized, trial concluded that operative management provided no improvement over non-operative care. The cost-effectiveness of operative management indicates that it is a moderately economically attractive treatment (a CU ratio of < $50,000). Further exploration of the impact of productivity losses is required. Funding: Dr. Brauer is supported by a grant from Alberta Heritage Foundation

During the last 2 decades it has been recognized that scoliosis may start de novo during adult life as a result of advanced degenerative disc disease, osteoporosis or both. In some the degenerative process is superimposed on a previous adolescent curve. Aside from the disfigurement caused by the spinal deformity, pain and disability are usually the major clinical problem. The prevalence of adult scoliosis rises with age: from 4% before age 45, 6% at age 59 to 15% in-patients older than 60 years. More than two thirds of the patients are females and the prevalence of right lumber curves is higher than in comparable series of patients with adolescent scoliosis. Adult scoliosis is characterized by vertebral structural changes with translatory shifts i.e. lateral olisthesis accompanied by degenerative disc and facet joint arthrosis. Although the magnitude of these curves is usually mild (20–30 degrees) lateral spondylolisthesis is observed frequently. It is also common to observe degenerative spondylolisthesis in patients with degenerative lumbar scoliosis. The annual rate of curve progression ranges from 0.3 to 3%. Patients present with a history of a spinal deformity accompanied by loss of lumbar lordosis, trunk imbalance and significant mechanical back pain. Pain may arise not only from degenerative disc disease and facet arthritis leading to symptoms of spinal stenosis, but also from muscle fatigue due to the altered biomechanics secondary to a deformity in the coronal and sagittal planes. Root entrapment is common and occurs more often on the concavity of the curve. Symptoms of neurogenic claudication are also common in adults with lumbar scoliosis. Non-operative care includes exercises, swimming, NSAIDs, and occasional epidural injections. Brace treatment can be tried as well. Curve progression as well as axial or radicular pain not responding to non-operative care are indications for surgical intervention. Surgery may include decompression alone or in conjunction with curve correction and stabilization. Posterior instrumentation may be supplemented with interbody cages. Fusion is usually carried down to L5 but occasional instrumentation to the sacropelvis is mandatory. Problems with a high pseudoarthrosis rate are common with sacral fixation. Even in the best of hands a long recovery period (6–12 month) and moderate pain relief should be expected. As summarized by Dr. Bradford “despite recent advancements evaluation and successful management of patients with adult spinal deformity remains a significant challenge”

Introduction Fusion has been the primary treatment for symptomatic disc degeneration unresponsive to non-operative care. The results for two-level fusion have generally been worse than for one-level. There is little information available concerning two-level total disc replacement (TDR), and none comes from prospective studies. The purpose of this study was to analyse the results of two-level disc replacement and compare these results to single-level cases performed at the same centre. Methods This data was collected from a single center participating in a multicentre a prospective, FDA-regulated clinical trial evaluating the ProDisc. This study is based on data from the first 105 patients (36 2-level and 69 one-level) enrolled who have reached a minimum of 12 months follow-up (data for 18 and 24 month were included if available at the time of data analysis). All patients were treated for symptomatic disc degeneration unresponsive to non-operative care. Data were collected pre-, peri-, and 6 weeks and 3, 6, 12, 18, and 24 months post-operatively. Outcome data included visual analog scale (VAS) assessing pain, Oswestry Disability Questionnaire, patient satisfaction (VAS ranging from 0 to 10), and a question asking patients if they would have the same surgery again. Within the 1-level and 2-level subgroups, pre- and postoperative data were compared to determine if there was improvement. The percentage of change in the pre- to post-operative scores was compared to determine if there were differences between the 1- and 2-level subgroups. Results The mean estimated blood loss (1-level= 57.7 cc vs. 2-level = 76.7 cc), operative time (1-level = 61.6 min vs. 2-level = 96.7 min) and length of hospitalization (1-level=1.86 days vs. 2-level= 2.36 days) were significantly less in the single-level cases (p< 0.05). VAS pain scores improved significantly (p< 0.05) in 1- and 2-level cases. The mean improvement in 2-level cases was 58.7% and in 1-level cases 62.4% (p> 0.05). Between the one and two-level cases, there was no significant difference in the percentage of patients who would have the surgery again (86.6% vs. 77.8%; p> 0.05). The mean satisfaction score in the single-level TDR group was 8.2 and was 7.1 in the 2-level group (maximum score of 10). Discussion This study found that both 1- and 2-level TDR results in significant improvement in pain and function scores. Patients undergoing 2-level disc replacement yielded outcomes similar to 1-level cases. These results support TDR as a viable treatment for 2-level symptomatic disc degeneration

Introduction. The management of chronic low back pain presents a formidable challenge to the spine specialist. This study was carried out to evaluate the efficacy of percutaneous nucleoplasty in patients affected by painful disc protrusions and contained herniations. Materials and Methods. 64 Patient's data collected from 2006 to 2009 in Princess Alexandra hospital. Minimum duration of non-operative care with back pain was 6 months. Patients were considered potential candidates for the study if they reported a clinical syndrome defined by a primary report of low back pain with or without lower extremity referral pain. Results. Out of 64 patients, 54 patient's full data collected. In that 28 male and 26 female with average age of 40.21and 43.11 yrs respectively. 40 patients underwent L45 level, 4 patients at L5S1, 9 patients at L45, L5S1 levels and 1 patient at 3 levels. Average Pre Op back VAS (Visual Analog Score) score 6.66, Leg VAS score 6.14 and Oswestry disability score 45.51. At 6months follow up back VAS score 4.5, Leg VAS score 3.14 and Oswestry disability score 20.03. Longest follow up with average 22 months (range from 12-36 months) with Back VAS score 5.09, Leg VAS score 3.64 and Oswestry disability score 36.25. Average pain reduction is significant - 50%-55%, and patient satisfaction is high - about 90%. Conclusion. By overcoming the limitations of prior methods of percutaneous discectomy, DISC Nucleoplasty has demonstrated the potential to produce equivalent, or even better, outcomes in a procedure that is simpler, quicker, and less traumatic and has faster recovery-times

Clavicle fracture account for about 44% of all adult fracture around the shoulder, although non-operative care results in high union rates for most, surgery is indicated in particular if displacement and/or shortening greater than 15–20 mm, lack of cortical apposition in young, healthy, active individual to yield the best clinical results in terms of alignment, union and early mobilisation. We did a retrospective audit to define the guidelines for admission, safer surgical approach and functional outcome using oxford score for the period Jan2002–Jan2007. This included 35pts, with Female: male ratio 1:2.5, Right: left side of 12:23, just over 50%were manual labours. Most common indication for surgery was displacement/shortening (16pts). 28 pts were operated within 4 weeks as acute admission. Direct incision was used in 14pts and infraclavicular incision in 21pts. Radiological union were seen in all pts on average 13.26 weeks (8 – 24wks). 10 patients had minor complications, 28% with direct incision and 19% with infraclavicular approach 29 patients went back to original work by 2.55 month, 5 excluded as 3 were at school, 2 unemployed and 1 did not mention. All patients had an oxford score of 12–20, showing satisfactory joint function. Metal work were removed in 6 patients, 2 (9.5%) in infraclavicular and 4 (28%) in direct incision. Conclusion: Our study included 35 patients, union were achieved in all with good functional results. 34 patients express to recommend surgical fixation to others. Infraclavicular approach was associated with less complication and less metal work removal

Aim. To review the evolution of the orthopaedic surgical care offered at a small rural hospital in western Nepal. The United Missions Hospital of Tansen (UMHT) was established in 1954 and has progressed substantially over the past 55 years. Located in the hills 300 km west of Kathmandu, it services not only Palpa District but also the surrounding nine districts and Indian patients from across the nearby border. The hospital has progressed from a simple medical clinic to a 165-bed hospital with four operating theatres, a new emergency department and multiple outpatient clinics. Orthopaedics in particular has come a long way from solely non-operative care such as plasters, splints and traction, to plating and intra-medullary nailing with intra-operative imaging facilities. This talk will review the progression of services in the region and highlight how western intervention has drastically improved the health care and lives of people in and around Tansen. Methods. UMHT is a 165-bed hospital with medical staff covering paediatrics, general medicine, general surgery and orthopaedics. Exact specialty coverage can vary depending on expatriate cover and locally trained staff expertise. There are around 315 Nepali employees, and eight mission appointees, mainly from the UK, USA, Australia and Sweden. There are six resident medical officers who are post internship and usually completing GP training schemes. The hospital is accredited to train 10 interns per year and frequently takes local and international medical students on rotation. Surgical facilities include daily outpatient surgical clinics of 30–60 patients, two minor operation theatres and two operating theatres. Generally, these are run as one orthopaedic and one general surgical theatre. This review is based on the experiences of Dr John Bosanquet, Dr Sandy Bosanquet and Dr Lachlan Host in their outreach trips to this hospital and in particular will focus on the progression over the last 10 years of the orthopaedic services available. Major advances have been in the provision of x-ray and CT facilities, improved supply of sterile equipment, introduction of IM nailing using the SIGN nail, and the training of local staff to continue the work. Conclusions. UMHT is a work in progress and is only made possible by the contributions of the many doctors, nurses, teachers and other professionals who willingly offer their services to help those less fortunate. Even more importantly is the funding provided from multiple organisations to sustain this outreach. The challenge remains, as in any outreach offered, of providing a service that is sustainable long-term. To date, UMHT has stood the test of time and there is much to be learnt from its example in the establishment of similar outreach projects. Future challenges for Tansen include the need for improved sterile facilities, the challenges of introducing elective surgery, particularly arthroplasty, provision of spine and neurosurgical facilities, and retention of skilled personal in what can be an isolating environment

Introduction: Reported standardized functional outcome assessment of flexion distraction injuries of the thoracolumbar spinal column seems to be lacking in the literature. The primary focus of this study was the long term functional outcome in this patient population in view of the management employed in a tertiary spine referral center. In an attempt to overcome the lack of pre-injury Health Related Quality of Life (HRQOL) data, patient recall of the pre-injury state was used. Secondary outcomes included the long-term disease-specific HRQOL in these patients, the correlation between radiographic alignment and functional outcome, comparison of HRQOL between operative and non-operative care, and identifying potential prognostic factors influencing functional HRQOL. Method: A database generated retrospective cohort study with a cross-sectional outcome analysis was carried out for patients with a thoracolumbar (T11-L2) flexion-distraction injury treated at a tertiary care referral center between 1995 and 2000. Inclusion criteria were age over sixteen, and referral to our center for a traumatic thoracolumbar flexion-distraction injury within two weeks of the injury. Exclusion criteria were an associated spinal cord injury, a previous spine injury or a multi-level spine injury, a significant associated other system injury with an ISS > 50, or patient refusal or inability to complete the outcome questionnaires. Patients were followed for a minimum of two years. Injury classification, healing, and alignment were determined by radiographic analysis. Standing lateral x-rays at final follow-up were used to determine the amount of residual kyphosis by two independent observers. Results: A total of 87 patients were identified by the research database, of which 83 met inclusion and exclusion criteria. Twenty-eight patients were lost to follow-up, leaving 55 eligible patients. Eight refused to participate. Of the 47 remaining patients, 40 completed questionnaires representing a response rate of 85%. There were 26 males and 14 females with a mean age of 27.4 years (range 16–48). Average follow-up was 3.3 years (range 2.5–7). Twenty-five patients (64.9%) were treated operatively and fifteen patients (35.1%) underwent non-operative management. Complications in the surgical group included one non-union, three cases of painful instrumentation, and one infection. In the non-surgical group, two patients developed non-unions requiring surgical intervention. Comparing the follow-up mean SF-36 PCS and MCS scores to the recalled baseline SF-36 pre-injury scores, demonstrated the patients did not return to baseline physical component and mental component scores (p < 0.001). The mental component (MCS) and NASS pain scores showed significant statistical difference between the two groups with a trend of non-surgical patients scoring higher. There was no statistically significant difference in the SF-36 PCS between the two groups. Linear and multiple regression models identified “associated other system injuries” as the only useful predictor of outcome influencing the SF-36 PCS. Patients with associated injuries are likely to have a poorer prognosis with lower scores. Radiographically, there was no association between degree of kyphosis at last follow-up and outcome. Discussion: Long term functional outcome assessment in this patient population and comparison between the surgical and non-surgical groups, revealed a trend in the non-surgical group towards reporting higher scores on both the generic and disease-specific questionnaires. There were also a higher number of complications associated with the surgical group, as well as potential residual back pain related to instrumentation. Limitations of the study were the retrospective nature of the study, as well as the inherent absence of real time pre-injury quality of life assessment. The study is, however, strengthened by a homogeneous cohort and the use of validated outcome measures. It also involves a cross-sectional analysis and so has a prospective component. Conclusion: The health related quality of life in patients treated for flexion-distraction injuries without spinal cord injury is favorable overall, but does not return to normal after an average of two years following injury, with a trend in the non-surgical group towards reporting higher scores on both the generic and disease-specific questionnaires. Radiographically, no association was found between degrees of focal kyphosis at last follow-up and functional outcome

This protocol describes a pragmatic multicentre randomised controlled trial (RCT) to assess the clinical and cost effectiveness of arthroscopic and open surgery in the management of rotator cuff tears. This trial began in 2007 and was modified in 2010, with the removal of a non-operative arm due to high rates of early crossover to surgery.

Cite this article: Bone Joint Res 2014;3:155–60.

The October 2014 Foot & Ankle Roundup360 looks at: multilayer compression bandaging superior for post-traumatic ankle oedema; compression stockings for ankle fractures; weight bearing ok in Achilles tendon ruptures; MRI findings can predict ankle sprain symptoms; salvage for malreduced ankle fractures; locking fibular plates are more expensive; is fixation better early or late in pilon fractures?; and calcaneal fracture fixation not for subtalar arthropathy