Purpose: A major issue in the Canadian health care system are the extensive wait times for consultation with an orthopaedic surgeon. We identified that a high percentage of patients referred to shoulder surgery sub-specialists for chronic full thickness rotator cuff tears had not undergone appropriate non-operative treatment prior to being referred, and ultimately did not require surgery. In an effort to improve the referral process and to optimize patient care, we sought to identify clinical predictors for outcome of non-operative treatment of chronic full-thickness rotator cuff tears. This would allow general practitioners to clearly identify patients who are most likely to fail non-operative treatment and actually require surgical consultation. The primary purpose of this study was to determine if the outcome of non-operative treatment in chronic, symptomatic, full-thickness rotator cuff tears could be predicted based upon presenting clinical characteristics, including: age, dominant extremity involvement, gender, duration of symptoms, onset (acute or chronic), forward elevation range of motion, external rotation strength, size of tear, smoking status, and the Rotator Cuff Quality of Life Questionnaire score (RCQOL). Method: Fifty patients, between the ages of 40 and 85 years, with a documented full-thickness tear on ultrasound or magnetic resonance imaging (MRI), were recruited prospectively. They underwent a three month home-based program of non-operative treatment under the supervision of an experienced physiotherapist and sport medicine physician. At the conclusion of the three month program, patients were evaluated by an orthopaedic surgeon and were defined as having been successful or as having failed non-operative treatment. Successful patients declined surgical treatment after consulting with the surgeon, whereas failed patients elected to undergo surgery, or, if avoiding surgery for other health or “life” reasons, had not experienced adequate improvement with the non-operative program to have been considered successful. The patient’s baseline clinical characteristics were analyzed using logistic regression to determine which characteristics were predictive of outcome. Results: Thirty-eight of 50 (76%) of patients were successful with the non-operative program. Univariate analysis showed that a patient’s Rotator Cuff Quality of Life questionnaire score was a significant predictor of outcome of non-operative treatment (p = 0.017). Patients who were successful with non-operative treatment had a mean baseline RCQOL score of 49/100, whereas patients who failed non-operative treatment had a mean baseline RCQOL score of 31/100. The two factors of patient age and dominant extremity involvement also trended toward significance. Conclusion: Baseline RCQOL score can predict which patients will be successful with non-operative treatment and which patients will fail non-operative treatment for a chronic, full-thickness rotator cuff tear

Introduction:. The treatment of acute rupture of the tendo-achilles remains controversial. There is good evidence to suggest that outcomes are the same for both operative and non-operative treatment when a functional rehabilitation program is utilised. However, debate continues as to whether the radiological gap-size between the proximal and distal remnants of the tendon has an influence on the suitability for non-operative management. Methods:. All adult patients who attended the emergency department with a clinically suspected tendo-achilles rupture were place in a plantarflexed cast, and underwent MRI scanning to confirm the diagnosis. They were then counselled on the risks and benefits of operative versus non-operative treatment. Patients opting for non-operative treatment were asked to take part in the study and treated using a functional rehabilitation programme. Gap sizes were determined using a standardised protocol by a single musculoskeletal radiologist blinded to the clinical outcomes. Results:. A total of 69 patients have been recruited into the study, 40 have complete their one year review. There were two re-ruptures. The average age was 42.4 years (range 19–70). The average gap size recorded by MRI was 40.4mm (range 6–110). The average ATRS score was 80 (range 17–100) and the single limb heel raise percentage of contralateral side was 64.8% (range 4–115). The Spearman rank correlation coefficient comparing gap size and ATRS score was 0.272 (p=0.045) and for gap size and strength was 0.158 (p=0.165). Conclusion:. This study shows a weak positive correlation between MRI measured gap size of the ruptured tendo-achilles and the Achilles tendon Total Rupture Score at one year. No correlation could be demonstrated between gap size and strength at one year. These results suggest that the MRI measured gap size is unimportant in predicting outcome and hence suitability for non-operative treatment of tendo-achilles rupture using functional rehabilitation

Background. Primary dislocation of the patella is a common acute knee disorder in children, adolescents and young adults. While primary dislocation of the patella has traditionally been treated non-operatively, primary operative repair of the medial patella-stabilizing soft tissues has been popularized more recently and thought to reduce the risk of dislocation. However, several studies have shown substantial rates of redislocation with longer follow-up time, irrespective of treatment. The purpose of this systematic review was to compare operative and non-operative treatment for primary dislocation of the patella, regarding redislocation rates and symptoms. Methods. Based on a systematic literature search of the medical literature from 1950 to 2010, three randomized and two quasi-randomized controlled clinical trials comparing surgical stabilization with non-operative treatment for patients with primary patellar dislocation were selected. The Risk of Bias Tool (Cochrane Handbook, 2008) was used to assess the quality of the studies included. Study results were pooled using the fixed-effects and random-effects models with mean differences and risk ratios for continuous and dichotomous variables, respectively. Heterogeneity across studies was assessed with Q test and I-square statistic. A sensitivity analysis was performed by assessing the change on effect size by eliminating each single trial. Results. In total, 341 patients from 5 trials were included. 158 patients were treated non-operatively and 183 patients were treated operatively. For primary outcome of patellar redislocation, while significant heterogeneity was found using the random-effects model, no significant difference was observed between the treatment groups (pooled RR=1.36, 95% CI 0.8–2.31, p=0.25). No significant difference was observed between the treatment groups (pooled RR=1.36, 95% CI0.8–2.31, p=0.25). No significant differences were found between both groups for symptoms ofinstability (RR of 1.24, 95% CI 0.96–1.59, p=0.10), Kujala knee score (−5.66, 95% CI −15.51 −4.19, p=0.26) or requirement for later surgery (RR=0.92, CI 0.61–1.39, p=0.69). Conclusions. This meta-analysis found no differences in patellar redislocation rate, patient reported instability symptoms, Kujala Knee score and rate of later surgery after initial treatment, between operative and non-operative treatment of primary patellar dislocation. Level of evidence. Level II

Acute achilles tendon ruptures are increasing in incidence and occur in 18 per 100 000 people per year, however there remains a lack of consensus on the best treatment of acute ruptures. Randomised studies comparing operative versus non-operative treatment show operative treatment to have a significantly lower re-rupture rate, but these studies have generally used non-weight bearing casts in the non-operative group. Recent series utilizing more aggressive non-operative protocols with early weight-bearing have noted a far lower incidence of re-rupture, with rates approaching those of operative management. Weight bearing casts may also have the advantages of convenience and an earlier return to work, and the purpose of this study was to compare outcomes of traditional casts versus Bohler-iron equipped weight-bearing casts in the treatment of acute Achilles tendon ruptures. 83 patients with acute Achilles tendon ruptures were recruited from three Auckland centres over a 2 year period. Patients were randomised within one week of injury to receive either a weight-bearing cast with a Bohler iron or a traditional non weight-bearing cast. A set treatment protocol was used, with a total cast time of eight weeks. Patients underwent detailed muscle dynamometry testing at 6 months, with further follow up at 1 year and at study completion. Primary outcomes assessed were patient satisfaction, time to return to work, and overall re-rupture rates. Secondary outcomes included return to sports, ankle pain and stiffness, footwear restrictions, and patient satisfaction. There were no significant differences in patient demographics or activity levels prior to treatment. At follow up, 1 patient (2%) in the Bohler iron group and 2 patients (5%) in the non weight bearing group sustained re-ruptures (p=0.62). There was a trend toward an earlier return to work in the weight-bearing group, with 58% versus 43% returning to work within 4 weeks, but the difference was not significant. 63% of patients in the weight bearing group reported freedom from pain at 12 months compared to 51 % in the non weight bearing group. There were no statistically significant differences in Leppilahti scores, patient satisfaction, or return to sports between groups. Weight-bearing casts in the non-operative treatment of Achilles tendon ruptures appear to offer outcomes that are at least equivalent to outcomes of non-weight bearing casts. The overall rerupture rate in this study is low, supporting the continued use of initial non-operative management in the treatment of acute ruptures

Mid-shaft humeral fractures in adults are common these days and often present with a management dilemma between operative and non-operative treatment. This study evaluates the outcome of such fractures treated non-operatively over a span of 10 years. In this retrospective study, a review of case notes and radiographs of patients whose mid-shaft humerus fractures were treated non-operatively between 1994 and 2004 was done. Those younger than 16 years and/or who had surgery primarily were excluded. Various factors including patient demographics, mechanism of injury, AO fracture classification and time to union were studied. Mean patient follow-up was 4 years and 6 months. The Oxford shoulder score was used for functional assessment. There was a total of 43 patients, mostly men with involvement of the dominant arm. 5 patients required open reduction and internal fixation with bone grafting for non-union. The average Oxford shoulder score was 18. The majority of patients could resume their jobs and the average time to union was 9 weeks. We conclude from this study that there is a high union rate in the mid-shaft humeral fractures in adults treated non-operatively, with an acceptable functional outcome

There is conflicting information regarding the recommendations of bracing, physical therapy and cessation of sports for young athletes with symptomatic spondylolysis. The purpose of this study was to identify factors affecting the prognosis and to find the optimal method of non-operative treatment. The patients in our study were athletes who visited our children's hospital for low back pain with lumbar spondylolysis and were treated non-operatively from 1990 to 2002. Clinical and radiological outcomes were reviewed retrospectively. The effects of bracing, physical therapy, cessation of sports, duration of symptoms before the first hospital visit, lateralisation of spondylolysis, age, gender, onset of low back pain after lumbar trauma during sports, bone scan uptake, vertebral level of the lesion, associated scoliosis or spina bifida and radiological bony healing were analysed using univariate and multivariate analysis with logistic regression. The mean age of patients was 13 years (range 7 to 18 years). The mean follow-up was 4.2 years (range 1.2 to 12 years). Of 132 patients, 48 patients had excellent results with no pain during sports, 76 good, 6 fair, and 4 poor. Cessation of sports, early non-operative intervention, and a unilateral spondylolysis appeared to be factors associated with excellent outcomes. However, bracing, physical therapy, age, gender, level of lesion, history of trauma, increased uptake on bone scan, or associated scoliosis or spina bifida were not factors. Bony healing was not related to the clinical outcome. The non-operative treatment of spondylolysis in children can yield excellent clinical outcomes, and the absence of bony healing has no influence on clinical outcome. Factors in this study found to correlate with an excellent outcome include unilateral spondylolysis, acute spondylolysis, and treatment with cessation of sports for 12 weeks

Objective: The development of braces for the non-operative treatment of idiopathic scoliosis has been empirical, based on trial and error. Brace designs have changed periodically over the years, but most modifications have been attempts to improve efficacy and failed to acknowledge the importance, especially to teenagers, of physical appearance. This group resists acting or looking different from their peers, which obviously occurs when a visible brace is worn. Modern materials, lower profiles, and reduced wearing times have been tried, in attempts to reduce resistance and the emotional difficulties encountered with brace wear. A transverse force system, consisting of an anterior progression force counteracted by a posterior force and torque, acts on the vertebrae of a scoliotic spine. The aim of the newly introduced TriaC brace is to reverse this transverse force pattern by externally applied and constantly present orthotic forces. In the frontal plane the force system is in accordance with the conventional braces. However, in the sagittal plane the force system acts only in the thoracic region. As a result, there is no pelvic tilt, and it provides flexibility without affecting the correction forces during body motion. Design: In 1996, when we almost completed the design of the new orthosis, we started a prospective trial in our University Hospital, which we expanded in the year 2000 to a prospective multi-center trial. Subjects: The study included 45 consecutive patients with idiopathic scoliosis treated since 1996 with the newly introduced brace. The group consisted of 40 female and 5 male patients with an average age at the initiation of treatment of 12,6 years. All patients were Risser zero to two and had verified progressive curves (an increase of 5 degrees or more Cobb angle). Results: Three parameters were measured during treatment: the Cobb angle, lateral deviation and axial rotation of the apex of the scoliotic curve. These measurements were conducted on digital X-rays using the Philips Easy Vision Digital Radiographic technique.[. 2. ] Statistical analysis for differences in time for the three measured parameters was performed using the Friedman’s two-way analysis of variance test. Level of significance was reached when the p-value (two-tailed) was less than 0,05. The new brace prevented further progression of the scoliotic curves, except for seven patients, who required surgery. The initial mean Cobb angle before brace treatment, was 26,5 degrees, the mean lateral displacement at the apex 18,5 millimetres, and the initial axial rotation of the apex was 12,3 degrees. Analysis of differences between each successive visit showed that the difference was not statistically significant for the Cobb angle (p=0,71), nor for the other parameters. Conclusions: This presentation shows that the preliminary results of the TriaC brace are very promising, but we acknowledge that our patient number is too small to make definite claims. Our failure rate is comparable with the numbers in literature. But being efficacious is not enough; this brace is reasonable comfortable and cosmetically acceptable so that the teenagers who require this treatment will use it

Decision-making regarding operative versus non-operative treatment of patients with thoracolumbar burst fractures in the absence of neurological deficits is controversial, and evidence from trials is sparse. We present a systematic review and meta-analysis of randomised trials comparing operative treatment to non-operative treatment in the management of thoracolumbar burst fractures. With the assistance of a medical librarian, an electronic search of Medline Embase and Cochrane Central Register of Controlled trials was performed. Trials were included if they: were randomided, had radiologically confirmed thoracolumbar (T10-L3) burst fractures, had no neurological deficit, compared operative and non-operative management (regardless of modality used), and had participants aged 18 and over. We examined the following outcomes: pain, using a visual analogue scale (VAS), where 0=no pain and 100=worst pain; function, using the validated Roland Morris Disability Questionnaire (RMDQ); and Kyphosis (measured in degrees). Two randomised trials including 79 patients (41 operative vs. 38 non-operative) were identified. Both trials had similar quality, patient characteristics, outcome measures, rates of follow up, and times of follow up (mean=47 months). Individual patient data meta-analysis (a powerful method of meta-analysis) was performed, since data was made available by the authors. There were no between-group differences in sex, level of fracture, mechanism of injury, follow up rates or baseline pain, kyphosis and RMDQ scores, but there was a borderline difference in age (mean 44 years in operative group vs. 39 in non-operative group, p=0.046). At final follow up, there were no between group differences in VAS pain (25 in operative group vs. 22 non-operative, p=0.63), RMDQ scores (6.1 in operative group vs. 5.8 non-operative, p=0.85), or change in RMDQ scores from baseline (4.8 in operative group vs. 5.3 non-operative, p=0.70). But both kyphosis at final follow up (11 degrees vs. 16 degrees, p=0.009) and reduction in kyphosis from baseline (1.8 degrees vs. -3.3 degrees, p=0.003) were better in the operative group. Operative management of thoracolumbar burst fractures appears to improve kyphosis, but does not improve pain or function

The purpose of this study was to examine five-year outcomes of patients previously enrolled in a non-operative rotator cuff study. Patients with chronic, full-thickness rotator cuff tears (demonstrated on imaging) who were referred to one of two senior shoulder surgeons were enrolled in the study between October 2008 and September 2010. Patients participated in a comprehensive non-operative, home-based treatment program. After three months patients were defined as “successful” or “failed”. “Successful” patients were essentially asymptomatic and did not require surgery. “Failed” patients were symptomatic and consented to surgical repair. All patients were followed up at one year, two years, and five-plus years. Original results of our study showed that 75% of patients were treated successfully with non-operative treatment, while 25% went on to surgery. These numbers were maintained at two-year follow-up (previously reported) and five-year follow-up. At five+ years, 88 patients were contacted for follow-up. Fifty-eight (66%) responded. The non-operative success group had a mean RC-QOL score of 80 (SD 18) at previously reported two-year follow-up. At five-year follow-up this score did not decrease (RCQOL = 82 (SD 16)). Furthermore, between two and five years, only two patients who had previously been defined as “successful” became more symptomatic and underwent surgical rotator cuff repair. From the original cohort of patients, those who failed non-operative treatment and underwent surgical repair had a mean RC-QOL score of 89 (SD 12) at five-year follow-up. The operative and non-operative groups at five-year follow-up were not significantly different (p = 0.07). Non-operative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. While some may argue that non-operative treatment delays inevitable surgical fixation, our study shows that patients can do extremely well over time

In January 2000 we introduced identical guidelines for the more rapid rehabilitation of Achilles tendon ruptures, whether treated operatively or non-operatively. A relaxed equinus cast was used to four weeks, then a CAM walker to eight weeks with supervised mobilisation. The aims of this study were to compare the outcomes of the operative and non-operative groups treated with the same rehabilitation program and audit the effectiveness of these guidelines. The audit was retrospective from January 2000 till January 2008. The patients were identified from the Emergency Department admissions database, the hospital clinical coding system, the department’s surgical audit data and the hospital physiotherapy appointment system. The audit system was used to identify patients that had complications of their operative treatment, re-ruptures or readmissions. This study focused on the end points of re-rupture, readmission, complications including wound complications and infection. Five hundred and eighty seven presentations were recorded as Achilles tendon injuries. One hundred and eighty patients were treated operatively and 407 patients were treated conservatively. Seventy five patients (42%) treated operatively and 126 patients (30%) of the non-operative group were rehabilitated in our hospital physiotherapy department. The remaining 386 patients (65.7% of all patients) received physiotherapy elsewhere or did not attend for further treatment. In the operative group there were two re-ruptures (1.1%) both treated in our hospital physiotherapy department. There were 2 wound complications (1.1%), one requiring re-operation. In the non operative group there were 15 re-ruptures (3.7%). Of these three had attended the hospital physiotherapy department (rerupture rate of 2.4%) In the non-operative group treated elsewhere there were 12 re-ruptures from 281 patients (4.2%). Comparable results were found between operative and non-operative treatment when combined with close physiotherapy guidance. Non-operatively treated patients treated in the community may have higher re-rupture rates. The results are comparable to those in the literature suggesting that the guidelines are effective

To assess the functional outcome of operative and non-operative treatment of distal humeral fractures in the elderly, patients above 75 years of age were studied. Demographic data including associated injuries and co-morbid conditions were recorded. The minimum follow-up was 16 months (range 16–92 months). Elbow function was analysed according to the OTA rating system. Radiographs were monitored for possible predictors of final functional outcome. Out of 125 patients with distal humeral fractures, 29 were above the age of 75 years. The mean age at the time of admission was 84.6 years (range 75–100). One patient was lost to follow-up. In total there were 28 patients with 29 fractures. 5 of these were open fractures. As per the AO classification, there were 8 type A, 8 type B, and 13 type C fractures. 8 patients were treated non-operatively (3 type A, 2 type B, 3 type C) and 21 (5 type A, 6 type B, 10 type C) operatively. An olecranon osteotomy was performed in 12 cases, 2 underwent triceps tongue reflection, and 7 had triceps splitting. Local complications included 4 cases (1 deep and 3 superficial) of infection and 3 non-unions (including one at the olecranon osteotomy). In the non-operative group the mean loss of extension and mean flexion achieved were 34.0 and 70.0 degrees respectively, whereas in the operative group the corresponding values were 23.0 and 107 degrees. OTA grading revealed 3 excellent, 9 good, 7 fair and 2 poor results in the operated group whereas in the non-operated group there were 0 excellent, 2 good, 3 fair, and 3 poor results. There was direct correlation between loss of anterior tilt of the distal humerus and adverse outcome. Conclusion: Our study showed that improved functional outcome can be achieved following surgical treatment in these difficult fracture This study supports the view that we need to re-examine the conventional view of ‘bag of bones’ method as blanket treatment and signifies the need for further studies on similar cohorts of patients

Purpose: To compare gait kinematics and kinetics in five-year old children treated initially with Ponseti casting versus French physical therapy. A third group, consisting of patients initially treated with these non-operative methods and then undergoing surgery consisting of more than a tendoachilles lengthening, was compared to those children treated entirely non-operatively. Method: Ninety patients (125 clubfeet) were tested at age five years. Thirty-four feet had undergone only Ponseti treatment, 40 the French program, and 51 had initial non-operative treatment with either the Ponseti or French protocols but later had surgery at an average age of 2+3 years. Kinematics and kinetics were compared to age-matched normal subjects. Results: Average stance-phase dorsiflexion did not differ between groups or from normal. Incidence of equinus: French 5%, Ponseti 0%; Increased stance-phase dorsiflexion: French 3%, Ponseti 24%, Surgical 18% (p < 0.05). A similar number of feet that were not operated upon at age five had in-toeing: 30% French, 32% Ponseti. Decreased ankle power generation at push-off: 53% French; 47% Ponseti; 67% Surgical. Average ankle power generation: 2.21 W/kg French, 2.36 W/kg Ponseti, 1.97 W/kg Surgical (2.83 W/kg in normal 5-year-old children). There was a difference in ankle power generation between normal feet and both the French and surgical groups (p< 0.001). Feet in the non-operative groups that had undergone Achilles tenotomy (n=28) had similar ankle power to those feet (n=42) that did not have tenotomies (p =0.223). Hip power generation was increased 33% in children who had undergone Ponseti treatment (1.38 W/kg), and 41% after French nonoperative treatment (1.47 W/kg), compared to normal (1.04 W/kg). This may be to compensate for poor ankle push-off. Conclusion: The gait characteristics of those feet that have not had surgery reveal that the majority had normal ankle kinematics, but reduced efficiency is demonstrated by reduced ankle push-off power, regardless of whether or not an Achilles tenotomy was performed. Decreased ankle power and persistant internal rotation are more frequently seen in feet that have undergone surgery despite initial nonoperative treatment, compared to those treated only by either the Ponseti protocol or the French physical therapy program

Purpose: The purpose of this randomised controlled trial was to compare outcomes of operative and non-operative management of Achilles tendon ruptures. Method: Patients with acute complete Achilles tendon ruptures were randomised to receive open suture repair followed by graduated rehabilitation or graduated rehabilitation alone. The primary outcome measure was re-rupture rate. Assessments at three and six months, and one and two years included a modified Leppelhati score (no strength data), range of motion, calf circumference, and isokinetic strength at one and two years. We report the two year findings. Results: Two centres randomized 145 patients (118 males and 27 females), mean age 40.9±8.8 years (22.5 – 67.2) to operative (n=73) and non-operative (n=72) treatment. Fourteen were lost to follow-up. Re-rupture occurred in three patients in both groups. The mean modified Lep-pelhati score (out of 85) was 78.2±7.7 in the operative group and 79.7±7.0 in the non-operative group, which was not significant (−1.5 95%CI −6.4 to 3.5, p=0.55). Mean side-to-side difference in plantar flexion and calf-circumference in the operative group was −2.0±3.2° and −1.4±1.2cm, and in the non-operative group −0.9±3.0°and −1.6±1.8cm respectively. Mean isokinetic plantar flexion strength was 62.4±24.2 for the operative and 56.7±19.3 for the non-operative group, which was not significant (5.7, 95%CI −3.1 to 14.5, p=0.20). There were a greater number of serious adverse events in the operative group, including pulmonary embolus in one patient, deep vein thrombosis in one and deep infections requiring irrigation and debridement in three. Conclusion: This study suggests that non-operative management of Achilles tendon ruptures utilizing an accelerated rehabilitation programme may produce comparable results with fewer adverse events

Purpose: Frozen shoulder or adhesive capsulitis is a painful and progressive loss of both active and passive range of motion without any known intrinsic cause. The natural history and histological stages have been described to help explain the pathogenesis. There have been conflicting reports evaluating the effects of intra-articular corticosteroid injections in the treatment to improve the natural history. We report our non-operative experience with the use of glenohumeral corticosteroid injections in patients diagnosed with adhesive capsulitis of the shoulder.

Method: 129 consecutive patients with a diagnosis of frozen shoulder were followed from 1997–2002. A detailed physical examination in both the erect and supine position documented range of motion. A VAS was used to document pain. All patients underwent a glenohumeral injection with 40 mg DepoMedrol and 9 ml 1% plain lidocaine at the time of initial presentation and at monthly follow-up with the following criteria: 1. No improvement in pain of 2 VAS levels 2. No improvement in erect abduction or forward flexion of 20° or 3. No improvement in erect or supine IR or ER of 10°. A maximum of 3 injections was used. Patients were followed until complete resolution of symptoms or if surgical intervention was needed. Successful treatment was considered if there was complete resolution of pain, full function, and patient satisfaction. Initial and follow-up ASES and HSS L’Insalata scores were recorded.

Results: Thirty-one patients were lost to follow-up leaving 98 patients to be evaluated. There were 69 females with average age of 40.7 years and 29 males with average age of 53.2 years. Overall success was 71.4% (71% females, 72.4% males). Successful treatment occurred at 4.15 months in females and 4.5 months in males. 85.7% of both female and male patients recovered with 1 or 2 injections. Poor prognostic indicators were Diabetes Mellitus, absent physiotherapy, workman’s compensation, post-operative stiffness cases, dominant arm, and stage 3 cases. Average ASES scores were 41.8 at presentation and 92.7 at resolution and HSS L’Insalata scores were 52.5 at presentation and 91.0 at resolution. There were no complications with our technique.

Conclusion: Glenohumeral corticosteroid injections for the patient with adhesive capsulitis are considered to be safe and an effective method of treatment for resolution of pain and improvement in functional range of motion. We recommend glenohumeral corticosteroid injections at the time of presentation and with close follow-up for frozen shoulder as part of the initial treatment regime. We have suggested an algorithm for the timing of intra-articular injections based on pain and objective range of motion.

Limited long term data exists comparing operatively and non-operatively treated Achilles tendon ruptures. A previous randomised controlled trial comparing early outcomes showed a short term advantage for surgery, but there are no long term prospective randomised comparisons. Our aim was to determine whether surgery conferred long term benefits in terms of patient reported outcomes or re-rupture.

64 patients (80%) were followed up with postal questionnaires. Patients were asked to complete the Short Musculoskeletal Function Assessment (SMFA), Achilles Tendon Total Rupture Score (ATRS) and EQ-5D questionnaires, and to report re-ruptures.

32 patients were treated non-operatively and 32 operatively; 59 completed the SMFA and 64 the ATRS and EQ-5D assessments. There was no significant difference in SMFA score (median 1.09, IQR 4.89 in the cast group versus 2.17 and 7.07 in the operative group; p=0.347), ATRS (median 96, IQR 18 versus 93 and 15; p=0.509), EQ-5D Index (median 1.0, IQR 0.163 versus 1.0 and 0.257; p=0.327) and EQ-5D Visual Analogue Score (median score 85, IQR 15 versus 85 and 24; p=0.650). There were 2 re-ruptures in the operative group and 4 in the non-operative group (p=0.067).

This is the first prospective, randomised, long term report comparing operative and non-operative management. At follow up between 13–17 years after injury, patients reported good function and health related quality of life. There was no significant difference in re-rupture rate between the treatment groups.

Patella fractures constitute 1% of all fractures and may disrupt the extensor mechanism of the knee. The mainstay of treatment for most patella fractures is operative fixation; however, patients with intact extensor mechanisms may be treated with splinting. We describe a series of patients with patella fractures managed non- operatively, without restricted weight bearing or splinting.

A consecutive series of 21 patients presenting with a patella fracture to two metropolitan hospitals were included in this study. All patients had an intact extensor mechanism but no distinction was made on age or fracture type. All patients were treated non-operatively with analgesia, were allowed to fully weight-bear and were not splinted. A retrospective review of the case notes was performed and data was collected with phone interview. The main outcome measure was the Western Ontario and McMaster Universities

Osteoarthritis (WOMAC) index, which has a maximum (worst) possible score of 240, and which provides an aggregate score of pain, stiffness and function. Mean time at follow up was 24 months (range 5–49 months). WOMAC scores were excellent (mean=18 of possible maximum 240; range 0–84). Only one patient had a significant complication related to their fracture (deep venous thrombosis), which was detected during hospital admission. Most patients had returned to usual work (9/14). No patients required operative fixation. There was no association between adjusted WOMAC score and age, sex, compensation status, time of follow up, or whether the patient had a significant ipsilateral injury. Patients who had returned to work (p=0.02) or who had lower levels of education (p=0.03) had better WOMAC scores.

Management of patella fractures with an intact extensor mechanism does not require restricted weight bearing or splinting.

Aims

The PROximal Fracture of the Humerus Evaluation by Randomisation (PROFHER) randomised clinical trial compared the operative and non-operative treatment of adults with a displaced fracture of the proximal humerus involving the surgical neck. The aim of this study was to determine the long-term treatment effects beyond the two-year follow-up.

Controversy exists as to whether burst fractures without neurological deficit should be treated operatively or non operatively. We assessed the functional outcomes of non operative treatment of burst fractures using the Oswestry disability index (ODI).

57 Patients who were treated non operatively (bed rest for one week and a corset for 3 months) were assessed using the Oswestry disability index (ODI) over a 6 month period. Assessments were done at an average of 4.8 years (range 18 months–7 years) post injury. There were 37 males and 22 females with an average age of 39 years. Fifty-three percent (31) injuries were due to a fall and twenty-two percent (22) followed an MVA. 90% Of fractures occurred between T12 and L2. Plain x-rays and CT scans were obtained to evaluate the burst fracture.

The initial average Cobb angle was nineteen degrees (19⁰) (range 6⁰–53⁰) with an average progression in Cobb angle was 7⁰ and the average final Cobb angle was 26⁰ (9⁰–71⁰) The average ODI was 17.32% (range 0 48%). Personal care, sexual activity and sleeping were not significantly affected (ODI : 0 or 1 each). Fifty-five percent (11/20) who were previously unemployed returned to work and none of those patients who were previously unemployed, were employed at a later date. All 11 housewives experienced no difficulty with household chores. This study revealed that 31 patients occasionally used analgesia (paracetamol).

The authors conclude that non operative treatment of burst fractures is a viable option in neurologically intact patients.

This study aimed to evaluate the effect of clavicular shortening, measured by three-dimensional computerized tomography (3DCT), on functional outcomes and satisfaction in patients with healed, displaced, midshaft clavicle fractures up to one year following injury.

The data used in this study were collected as part of a multicenter, prospective randomized control trial comparing open reduction and plate fixation with nonoperative treatment for displaced midshaft clavicle factures. Patients who were randomized to nonoperative treatment and who had healed by one year were included. Clavicle shortening relative to the uninjured contralateral clavicle was measured on 3DCT. Outcome analysis was conducted at six weeks, three months, six months and one year following injury and included the Disabilities of the Arm, Shoulder and Hand (DASH), Constant and Short Form-12 (SF-12) scores, and patient satisfaction.

48 patients were included. The mean shortening of injured clavicles, relative to the contralateral side, was 11mm (+/− 7.6mm) with a mean proportional shortening of 8percnt;. Proportional shortening did not significantly correlate with the DASH (p>0.42), Constant (p>0.32) or SF-12 (p>0.08) scores at any time point. There was no significant difference in the mean DASH or Constant scores at any followup time point both when the cut off for shortening was defined as one centimeter (p>0.11) or two centimeters (p>0.35). There was no significant difference in clavicle shortening between satisfied and unsatisfied patients (p>0.49).

This study demonstrated no association between shortening and functional outcome or satisfaction in patients with healed, displaced, midshaft clavicle fractures up to one year following injury.

Introduction: The optimal management of ankle fractures in the elderly is controversial, with wide variation in the complication rates reported in the literature. Achieving a satisfactory outcome is essential as reduced mobility exacerbates pre-existing morbidity and diminishes the likelihood of independent living. However, in elderly patients surgery carries increased risks due to osteoporosis, poor skin condition and decreased vascularity.

Methods: We performed a retrospective review of outcome and complications in patients over 70 years of age with ankle fractures. Patients were admitted for manipulation under anaesthetic and application of cast (MUA) or open reduction and internal fixation (ORIF). Data were retrieved from medical and nursing notes relating to pre-operative functioning, type of injury, operative procedure and outcome. All X-rays were also reviewed to confirm fracture grade and union.

Results: A total of 134 patients over the age of 70 were admitted for management of ankle fractures during January 1995 and December 2003 and 117 of these were included in the study. 84 were operatively treated for ankle fractures and a further 27 patients underwent MUA. The mean age in both groups was 76 and there was a female predominance in both groups (89% in MUA, 79% in ORIF). 14.8% of the conservatively managed group were nursing home residents compared to 2.4% of the operatively treated group. The groups were similar with respect to ASA grade and co-morbidities. The median length of stay was shorter for the conservatively managed group (4 vs. 6 days). 7.5% of the MUA group required a second intervention compared to 4.5% of the operatively managed group. There were two below knee amputations in the operatively managed group, both related to open fractures, and one arthrodesis in each group. There were three wound complications in the operatively managed group. The rate of postoperative medical complications was the same in both cohorts. 7.4% of patients treated with MUA and 1.1% of patients treated operatively had reduced mobility at final follow-up.

Conclusion: The decision-making process for treatment of ankle fractures in the geriatric population is challenging. We observed significantly better functional results in the ORIF group than the MUA group. These results indicate that open reduction and internal fixation of ankle fractures in geriatric patients is efficacious and safe in selected patients