Aims. To identify factors influencing clinicians’ decisions to undertake a
Aims. To assess the proportion of patients with distal radius fractures (DRFs) who were managed
Aims. The aim of this study was to investigate the association between fracture displacement and survivorship of the native hip joint without conversion to a total hip arthroplasty (THA), and to determine predictors for conversion to THA in patients treated
Unstable ankle fractures are routinely managed operatively. Due to soft-tissue and implant related complications, there has been recent literature reporting on the non-operative management of well-reduced medial malleolus fractures following fibular stabilisation, but with limited evidence supporting routine application. This trial assessed the superiority of internal fixation of well-reduced (displacement ≤2mm) medial malleolus fractures compared with non-fixation following fibular stabilisation. Superiority, pragmatic, parallel, prospective randomised clinical trial conducted over a four year period. A total of 154 adult patients with a bi- or trimalleolar fractures were recruited from a single centre. Open injuries and vertical medial malleolar fractures were excluded. Following fibular stabilisation, patients were randomised intra-operatively on a 1:1 basis to fixation or non-fixation after satisfactory fluoroscopic fracture reduction was confirmed. The primary outcome was the Olerud Molander Ankle Score (OMAS) at one-year post-randomisation. Complications and radiographic outcomes were documented over the follow-up period.Introduction
Methods and participants
This prospective randomised trial aimed to assess the superiority of internal fixation of well-reduced medial malleolar fractures (displacement □2mm) compared with non-fixation, following fibular stabilisation in patients undergoing surgical management of a closed unstable ankle fracture. A total of 154 adult patients with a bi- or trimalleolar fracture were recruited from a single centre. Open injuries and vertically unstable medial malleolar fractures were excluded. Following fibular stabilisation, patients were randomised intra-operatively on a 1:1 basis to fixation or non-fixation after satisfactory fluoroscopic fracture reduction was confirmed. The primary outcome was the Olerud Molander Ankle Score (OMAS) at 12 months post-randomisation. Complications were documented over the follow-up period. The baseline group demographics and injury characteristics were comparable. There were 144 patients reviewed at the primary outcome point (94%). The median OMAS was 80 (IQR, 60-90) in the fixation group vs. 72.5 (IQR, 55-90) in the non-fixation group (p=0.165). Complication rates were comparable, although significantly more patients (n=13, 20%) in the non-fixation group developed a radiographic non-union (p<0.001). The majority (n=8/13) were asymptomatic, with one patient requiring surgical reintervention. In the non-fixation group, a superior outcome was associated with an anatomical medial malleolar fracture reduction. Internal fixation is not superior to non-fixation of well-reduced medial malleolar fractures when managing unstable ankle fractures. However, one in five patients following non-fixation developed a radiographic non-union and whilst the re-intervention rate to manage this was low, the longer-term consequences of this are unknown. The results of this trial may support selective non-fixation of anatomically reduced fractures.
Acute metatarsal fractures are a common extremity injury. While surgery may be recommended to reduce the risk of nonunion or symptomatic malunion, most fractures are treated with
There is very limited literature describing the outcomes of management for proximal humerus fractures with more than 100% displacement of the head and shaft fragments as a separate entity. This study aimed to compare operative and non-operative management of the translated proximal humerus fracture. A prospective cohort study was performed including patients managed at a Level 1 trauma centre between January 2010 to December 2018. Patients with 2, 3 and 4-part fractures were included based on the degree of translation of the shaft fragment (≥100%), resulting in no cortical contact between the head and shaft fragments. Outcome measures were the Oxford Shoulder Score (OSS), EQ-5D-5L, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, and non-union/malunion. Linear and logistic regression models were used to compare management options. There were 108 patients with a proximal humerus fracture with ≥100% translation; 76 underwent operative management and 32 were managed non-operatively with sling immobilisation. The mean (SD) age in the operative group was 54.3 (±20.2) and in the non-operative group was 73.3 (±15.3) (p<0.001). There was no association between OSS and management options (mean 38.5(±9.5) operative vs mean 41.3 (±8.5) non-operative, p=0.48). Operative management was associated with improved health status outcomes; EQ-5D utility score adjusted mean difference 0.16 (95%CI 0.04-0.27, p=0.008); EQ-5D VAS adjusted mean difference 19.2 (95%CI 5.2-33.2, p=0.008). Operative management was further associated with a lower odds of non-union (adjusted OR 0.30, 95%CI 0.09-0.97, p=0.04), malunion (adjusted OR 0.14, 95%CI 0.04-0.51, p=0.003) and complications (adjusted OR 0.07, 95%CI 0.02-0.32, p=0.001). Translated proximal humerus fractures with ≥100% displacement demonstrate improved health status and radiological outcomes following surgical fixation. Patients with this injury should be considered for operative intervention.
Introduction. The purpose of this study is to estimate the cost-effectiveness of performing total hip arthroplasty (THA) versus
Metacarpal fractures represent up to 33% of all hand fractures; of which the majority can be treated non-operatively. Previous research has shown excellent putcomes with non-operative treatment yet surgical stabilisation is recommended to avoid malrotation and symptomatic shortening. It is unknown whether operative is superior to non-operative treatment in oblique or spiral metacarpal shaft fractures. The aim of the study was to compare non-operative treatment of mobilisation with open surgical stabilisation. 42 adults (≥ 18 years) with a single displaced oblique or spiral metacarpal shaft fractures were randomly assigned in a 1:1 pattern to either non-operative treatment with free mobilisation or operative treatment with open reduction and fixation with lag screws in a prospective study. The primary outcome measure was grip-strength in the injured hand in comparison to the uninjured hand at 1-year follow-up. The Disabilities of the Arm, Shoulder and Hand Score, ranges of motion, metacarpal shortening, complications, time off work, patient satisfaction and costs were secondary outcomes. All 42 patients attended final follow-up after 1 year. The mean grip strength in the non-operative group was 104% (range 73–250%) of the contralateral hand and 96% (range 58–121%) in the operatively treated patients. Mean metacarpal shortening was 5.0 (range 0–9) mm in the non-operative group and 0.6 (range 0–7) mm in the operative group. There were five minor complications and three revision operations, all in the operative group. The costs for non-operative treatment were estimated at 1,347 USD compared to 3,834USD for operative treatment; sick leave was significantly longer in the operative group (35 days, range 0–147) than in the non-operative group (12 days, range 0–62) (p=0.008). When treated with immediate free mobilization single, patients with displaced spiral or oblique metacarpal shaft fractures have outcomes that are comparable to those after operative treatment, despite some metacarpal shortening. Complication rates, costs and sick leave are higher with operative treatment. Early mobilisation of spiral or long oblique single metacarpal fractures is the preferred treatment. Trial registration number: ClinicalTrials.gov NCT03067454
Diabetes has been associated with greater risk of complications and prolonged postoperative recovery following ankle trauma. Our cohort study seeks to review the operative management and outcomes of ankle fractures in diabetic adults relative to non-diabetic adults. Cases were identified using ICD-10 coding criteria. 572 patients from Jan 2016–2019 presented with ankle fractures; 34 in diabetic patients. Mechanism of injury and stability were determined from the index radiograph using a validated Lauge-Hansen classification algorithm. Admission, primary post-operative and discharge radiographs were reviewed independently by two foot and ankle reconstruction specialists to assess adequacy of fixation method. 32% of diabetic patients were managed non-operatively compared to 29% of the matched non-diabetic cohort. The distribution in Lauge-Hansen fracture pattern was comparable between cohorts. Non-diabetic controls were frequency age-matched 2:1.Abstract
Objectives
Methods
Diabetes has been associated with greater risk of complications and prolonged postoperative recovery following ankle trauma. Our cohort study reviewed the operative management and outcomes of ankle fractures in diabetic adults relative to non-diabetic adults from Jan 2016–2019. Non-diabetic controls were frequency age-matched 2:1. 34 of 572 ankle fracture presentations were in diabetic patients, 32% managed non-operatively compared to 29% of the matched non-diabetic cohort. The distribution in Lauge-Hansen fracture pattern was comparable between cohorts. Mean length of follow-up was significantly longer for diabetics (26 weeks) compared to non-diabetics (16 weeks). Post-operative wound complications (superficial wound infection, breakdown, dehiscence) occurred in 48% of the operated diabetic ankles, compared to 5% in non-diabetics (RR 8.1, 95% CI 2.5–26.4). Reoperation (RR 4.3, 95% CI 2.5–26.4, Poorly controlled diabetes is associated with substantially greater complication rates following ankle fracture than those with well controlled or normal blood sugar; high HbA1c > 69mmol/mol is a significant predictor of complicated follow-up. Locally we recommend management strategies that are influenced by the fracture pattern stability and the presence or absence of complicated or poorly managed diabetes.
This single-centre prospective randomised trial aimed to assess the superiority of operative fixation compared with non-operative management for adults with an isolated, closed humeral shaft fracture. 70 patients were randomly allocated to either open reduction and internal fixation (51%, n=36/70) or functional bracing (49%, n=34/70). 7 patients did not receive their assigned treatment (operative n=5/32, non-operative n=2/32); results were analysed based upon intention-to-treat. The primary outcome measure was the DASH score at 3 months. Secondary outcomes included treatment complications, union/nonunion, shoulder/elbow range of motion, pain and health-related quality of life (HRQoL). At 3 months, 66 patients (94%) were available for follow-up; the mean DASH favoured surgery (operative 24.5, non-operative 39.4; p=0.006) and the difference (14.9 points) exceeded the MCID. Surgery was also associated with a superior DASH at 6wks (operative 38.4, non-operative 53.1; p=0.005) but not at 6 months or 1yr. Brace-related dermatitis affected 7 patients (operative 3%, non-operative 18%; OR 7.8, p=0.049) but there were no differences in other complications. 8 patients (11%) developed a nonunion (operative 6%, non-operative 18%; OR 3.8, p=0.140). Surgery was associated with superior early shoulder/elbow range of motion, and pain, EuroQol and SF-12 Mental Component Summary scores. There were no other differences in outcomes between groups. Surgery confers early advantages over bracing, in terms of upper limb function, shoulder/elbow range of motion, pain and HRQoL. However, these benefits should be considered in the context of potential operative risks and the absence of any difference in patient-reported outcomes at 1yr.
Introduction:. Isolated Weber B lateral malleolus fractures heal uneventfully, but concern that late subluxation may occur due to unrecognised medial ligament tearing, despite an intact mortice on initial radiographs, often results in overtreatment. The aim of this study was to determine the incidence of late talar shift with
This systematic review and meta-analysis aimed to compare the outcome of operative and non-operative management in adults with distal radius fractures, with an additional elderly subgroup analysis. The main outcome was 12-month PRWE score. Secondary outcomes included DASH score, grip strength, complications and radiographic parameters. Randomised controlled trials of patients aged ≥18yrs with a dorsally displaced distal radius fractures were included. Studies compared operative intervention with non-operative management. Operative management included open reduction and internal fixation, Kirschner-wiring or external fixation. Non-operative management was cast/splint immobilisation with/without closed reduction. Version 2 of the Cochrane risk-of-bias tool was used. After screening 1258 studies, 16 trials with 1947 patients (mean age 66yrs, 76% female) were included in the meta-analysis. Eight studies reported PRWE score and there was no clinically significant difference at 12 weeks (MD 0.16, 95% confidence interval [CI] −0.75 to 1.07, p=0.73) or 12 months (mean difference [MD] 3.30, 95% CI −5.66 to −0.94, p=0.006). Four studies reported on scores in the elderly and there was no clinically significant difference at 12 weeks (MD 0.59, 95% CI −0.35 to 1.53, p=0.22) or 12 months (MD 2.60, 95% CI −5.51 to 0.30, p=0.08). There was a no clinically significant difference in DASH score at 12 weeks (MD 10.18, 95% CI −14.98 to −5.38, p<0.0001) or 12 months (MD 3.49, 95% CI −5.69 to −1.29, p=0.002). Two studies featured only elderly patients, with no clinically important difference at 12 weeks (MD 7.07, 95% CI −11.77 to −2.37, p=0.003) or 12 months (MD 3.32, 95% CI −7.03 to 0.38, p=0.08). There was no clinically significant difference in patient-reported outcome according to PRWE or DASH at either timepoint in the adult group as a whole or in the elderly subgroup.
We aimed to evaluate if union of clavicle fractures can be predicted at six weeks post-injury by the presence of bridging callus detected by ultrasound. Adult patients who sustained a displaced midshaft clavicle were recruited prospectively. We assessed patient demographics, functional scores and radiographic predictors with a standardized protocol at six weeks. Ultrasound evaluation of the fracture site was undertaken to determine if sonographic bridging callus was present. Nonunion was determined by CT scanning at six months post-injury. Clinical features at six weeks were used to stratify patients at high risk of nonunion and a QuickDASH ≥40, fracture movement on examination or absence of callus on radiograph.Abstract
Objectives
Methods
Non-operative management of displaced olecranon fractures in elderly low demand patients is reported to result in a satisfactory outcome despite routinely producing a nonunion. The aim of this study was to assess whether there is evidence of dynamic movement of the fracture fragment during the elbow arc of movement. Five consecutive patients (≥70 years of age) with a displaced olecranon fracture (Mayo 2A) that were managed with non-operative intervention were recruited. All underwent ultrasound evaluation at six weeks and follow-up questionnaires at six months including the DASH and Oxford Elbow Score (OES). There were three women and two men with a mean age of 79yrs (range 70–88). All injuries were sustained following a fall from standing height. The mean fracture gap in extension was 22.5mm (95% CI 13.0–31.9), midflexion 21.8mm (11.6–32.0) and in deep flexion 21.8mm (10.9–32.8). Although the amount of fracture displacement varied between patients, it remained static in each patient with no significant differences observed throughout the arc of motion (ANOVA p=0.99). The six-month median DASH score was 7.5 (IQR range, 4.2–39.3) and the OES was 44.0 (29.0–47.5). Four out of the five patients were satisfied with their function. Ultrasound evaluation of displaced olecranon fractures following non-operative management suggests the proximal fragment may function as a sesamoid type bone within the triceps sleeve. This could explain how a functional arc of movement with a minimum level of discomfort can usually be expected with non-operative management in select patients.
We outline a treatment protocol for subjects with chronic periprosthetic joint infections (PJI) who elected not to have surgery. We developed a method of serial “fluid-depleting” aspirations with intra-articular gentamycin injections to affect the population of the biofilm community. We have experienced many treatment failures, as expected, but have also had a group of subjects who responded exceptionally well, requiring no surgical intervention. Our longest follow-up is 10 years. From June 2009 to December 2018, 372 clinical cases of chronic PJI involving primary and revision TKA and THA were treated. Of these, 25 subjects were treated with an active suppression protocol, in lieu of surgery. The protocol entailed frequent aspirations and intra-articular antibiotic injections to quell the PJI inflammatory response. All aspirations were performed by the treating surgeon in the orthopaedic clinic without fluoroscopic guidance. Based on a subject's response to the protocol, he/she was identified as 1 of 3 classifications: 1) Ongoing Treatment – Biofilm Trained (OTBT), 2) Ongoing Treatment – Biofilm Untrained (OTBU), and 3) Treatment Failure (TF). OTBT subjects showed no clinical signs of infection. Serum biomarkers (CRP, ESR) remained consistently normal and subjects were not on oral suppressive antibiotics. Aspiration analysis and cultures remained negative. Maintenance treatment consisted of a fluid-depleting aspiration with an intra-articular gentamycin injection every 12–16 weeks. OTBU subjects showed improved clinical symptoms, lowered serum biomarkers, and lowered WBC counts, but still demonstrated objective signs of infection. TF subjects did not respond to the protocol and showed unchanged/worsening clinical symptoms.Aim
Method
Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is
Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is
Aims. It is unclear whether acute plate fixation facilitates earlier return of normal shoulder function following a displaced mid-shaft clavicular fracture compared with