The traditional treatment for a primary anterior shoulder dislocation has been immobilisation in a sling with the arm in adduction and internal rotation. The recurrence rates after the initial traumatic event range from 20% to 94%. However, recent results have suggested that recurrent instability after primary shoulder dislocation may be reduced with immobilisation in external rotation. Since then, controversy exists regarding the position of immobilisation following these injuries. The objective of the present study was to compare immobilisation in internal and external rotation after a primary anterior shoulder dislocation.

Fifty patients presenting to our fracture clinic with a primary traumatic anterior dislocation of the shoulder were randomly assigned to treatment with immobilisation in either internal rotation (IR; 25 patients) or external rotation (ER; 25 patients) for three weeks. In addition of a two-years clinical follow-up, patients underwent a magnetic resonance imaging (MRI) of the shoulder with intra-articular contrast within four days following the traumatic event, and then at three months of follow-up. The primary outcome was a recurrent dislocation within 24 months of follow-up. The secondary outcome was the healing rate of the labral lesion seen on MRI (if present) within each immobilisation group.

The follow-up rate after two years was 92% (23 of 25) in the IR group and 96% (24 of 25) in the ER group. The recurrence rate in the IR group (11 of 23; 47.8%) was higher than that in the ER group (7 of 24; 29.2%) but the difference did not reach statistical significance (p=0.188). However, in the subgroup of patients aged 20–40 years, the recurrence rate was significantly lower in the ER group (3 of 17; 6.4%) than that in the IR group (9 of 18; 50%, p<0,01). In the subgroup of patients with a labral lesion present on the initial MRI, the healing rate of the lesion was 46.2% (6 of 13) in the IR group and 60% (6 of 10) in the ER group (p=0.680). Overall, the recurrence rate among those who showed healing of the labrum (regardless of the immobilisation group) was 8.3% (1 of 12), but patients who did not healed their labrum had a recurrence rate of 45.5% (5 of 11; p=0.069).

This study suggests that immobilisation in ER reduces the risk of recurrence after a primary anterior shoulder dislocation in patients aged between 20 and 40 years. At two years follow-up, the recurrence rate is lower in patients who demonstrated a healed labrum at three months, regardless of the position of immobilisation. Future studies are required in order to identify factors that can improve healing of the damaged labrum following a traumatic dislocation of the shoulder.

Rotator cuff repair is performed to treat shoulder pain and disability. Failure of the tendon repair site is common; one strategy to improve healing is to enforce a period of post-operative immobilisation. Immobilisation may have unintended effects on tendon healing. Tenocytes under uniaxial strain form more organised collagen and up regulate expression of proliferative genes. Vitamin C (ascorbic acid), an anti-oxidant that is a co-factor for collagen synthesis, has also been reported to enhance collagen deposition and organisation. The purpose of this study was to compare human tenocyte cultures exposed to uniaxial cyclical strain with or without slow-release ascorbic acid (ascorbyl-2 phosphate) to determine their individual and combined effects on tissue remodelling and expression of tissue repair genes. Rotator cuff tissues were collected from degenerative supraspinatus tears from eight patients. Tenocytes were incorporated into 3D type I collagen culture matrices. Cultures were divided into four groups: 1) ascorbic acid (0.6mMol/L) + strain (1%–20% uniaxial cyclic strain at 0.1 Hz), 2) ascorbic acid unstrained, 3) strain + vehicle 4) unstrained + vehicle. Samples were fixed in paraffin, stained with picrosirius red and analysed with circular polarising light. A second set of cultures were divided into three groups: 1) 0.5mM ascorbic acid, 2) 1mM ascorbic acid, 3) vehicle cultured for 24, 72, 120 and 168 hours. Cell-free collagen matrix was used as a control. Tenocyte proliferation was assessed using the water soluble tetrazolium-1 (WST1) assay and f tissue repair gene expression (TGFB1, COL1A1, FN1, COLIII, IGF2, MMP1, and MMP13), were analysed by qPCR. The data were analysed using a Split model ANOVA with contrast and bonferroni correction and a one-way ANOVAs and Tukey's test (p<0.05 was significant). Our results indicated that unstrained cultures with or without exposure to slow release ascorbic acid exhibited greater picrosirius red birifringency and an increase in collagen fiber deposition in a longitudinal orientation compared to strained tenocytes. We found that slow release ascorbic acid promoted significant dose and culture-time dependent increases in tenocyte proliferation (p<0.05) but no obvious enhancement in collagen deposition was evident over cultures without ascorbic acid supplementation. Based on these data, applying strain to tenocytes may result in less organised formation of collagen fibers, suggestive of fibrotic tissue, rather than tendon remodelling. This may indicate that a short period of immobilisation post-rotator cuff repair is beneficial for the healing of tendons. Exposure to slow release ascorbic acid enhanced tenocyte proliferation, suggesting that supplementation with Vitamin C may improve tendon repair post-injury or repair. Future studies will assess levels of tissue repair-associated proteins as well as comparing traumatic and degenerative rotator cuff tears to healthy uninjured rotator cuff tissue

Aims. The purpose of this study was to compare symptomatic treatment of a fracture of the base of the fifth metatarsal with immobilisation in a cast. Our null hypothesis was that immobilisation gave better patient reported outcome measures (PROMs). The alternative hypothesis was that symptomatic treatment was not inferior. Patients and Methods. A total of 60 patients were randomised to receive four weeks of treatment, 36 in a double elasticated bandage (symptomatic treatment group) and 24 in a below-knee walking cast (immobilisation group). The primary outcome measure used was the validated Visual Analogue Scale Foot and Ankle (VAS-FA) Score. Data were analysed by a clinician, blinded to the form of treatment, at presentation and at four weeks, three months and six months after injury. Loss to follow-up was 43% at six months. Multiple imputations missing data analysis was performed. Results. At four weeks and six months, symptomatic treatment proved non-inferior in terms of primary outcome. Take home message: Immobilisation is no better than symptomatic treatment in the management of a fracture of the base of the fifth metatarsal when judged by PROMs. Significant loss to follow-up with this injury could be expected in longer term. Cite this article: Bone Joint J 2016;98-B:806–11

Operative and non-operative treatment regimens for Achilles tendon ruptures vary greatly but commonly involve rigid casting or functional bracing. The aim of our study was to investigate the extent of tendon apposition following such treatments.

Twelve fresh-frozen, adult below knee lower-extremity cadaveric specimens with intact proximal tibiofibular joints were used. Each was prepared by excising a 10cm × 5cm skin and soft tissue window exposing the Achilles tendon. With the ankle in neutral position, the tendon was transfixed with a 2mm k-wire into the tibia, 8cm from its calcaneal insertion. A typical post-rupture gap was created by excising a 2.5cm portion of tendon between 3.5cm and 6cm from its calcaneal insertion.

The specimens were then placed into a low profile walker boot (SideKICK^TM, Procare) without wedges and a window cut into the back. The distance between the proximal and distal Achilles tendon cut edges was measured and repeated with 1, 2 and 3 (10mm) wedges. Subsequently the specimens were placed into a complete below knee cast in full equinus which was also windowed.

The Achilles tendon gap (mean +/− SD) measured: 2.7cm (0.5) with no wedge, 2.3cm (0.4) with 1, 2.0cm (0.4) with 2, 1.5cm (0.4) with 3 wedges and 0.4cm (0.3) in full equinus cast.

The choice of treatment had a significant effect on tendon gap (p< 0.0001 – repeated measures ANOVA), and all pairwise comparisons were significantly different (Bonferroni), with all p< 0.001, apart from 0 wedge vs. 1 wedge (p< 0.01) and 1 wedge vs. 2 wedges (p< 0.05).

Our results showed that each wedge apposed the tendon edges by approximately 0.5cm with the equinus cast achieving the best apposition. Surgeons should consider this when planning appropriate immobilisation regimes for Achilles tendon ruptures.

The natural history of primary anterior dislocation of the glenohumeral joint in adolescent patients remains unclear and there is no consensus for management of these patients.

The objectives of this study were to report the natural history of primary anterior dislocation of the glenohumeral joint in adolescent patients and to identify the risk factors for recurrent dislocation.

We reviewed prospectively-collected clinical and radiological data on 133 adolescent patients diagnosed with a primary anterior dislocation of the glenohumeral joint who had been managed non-operatively at our hospital between 1996 and 2008. There were 115 male (86.5%) and 18 female patients (13.5%) with a mean age of 16.3 years (13 to 18) and a mean follow-up of 95.2 months (1 to 215).

During follow-up, 102 (absolute incidence of 76.7%) patients had a recurrent dislocation. The median interval between primary and recurrent dislocation was ten months (95% CI 7.4 to 12.6). Applying survival analysis the likelihood of having a stable shoulder one year after the initial injury was 59% (95% CI 51.2 to 66.8), 38% (95% CI 30.2 to 45.8%) after two years, 21% (95% CI 13.2 to 28.8) after five years, and 7% (95% CI 1.1 to 12.9) after ten years. Neither age nor gender significantly predicted recurrent dislocation during follow-up.

We conclude that adolescent patients with a primary anterior dislocation of the glenohumeral joint have a high rate of recurrent dislocation, which usually occurs within two years of their initial injury: these patients should be considered for early operative stabilisation.

Cite this article: Bone Joint J 2015;97-B:520–6.

A small proportion of children with Gartland type III supracondylar humeral fracture (SCHF) experience troubling limited or delayed recovery after operative treatment. We hypothesised that the fracture level relative to the isthmus of the humerus would affect the outcome.

We retrospectively reviewed 230 children who underwent closed reduction and percutaneous pinning (CRPP) for their Gartland type III SCHFs between March 2003 and December 2012. There were 144 boys and 86 girls, with the mean age of six years (1.1 to 15.2). The clinico-radiological characteristics and surgical outcomes (recovery of the elbow range of movement, post-operative angulation, and the final Flynn grade) were recorded. Multivariate analysis was employed to identify prognostic factors that influenced outcome, including fracture level. Multivariate analysis revealed that a fracture below the humeral isthmus was significantly associated with poor prognosis in terms of the range of elbow movement (p < 0.001), angulation (p = 0.001) and Flynn grade (p = 0.003). Age over ten years was also a poor prognostic factor for recovery of the range of elbow movement (p = 0.027).

This is the first study demonstrating a subclassification system of Gartland III fractures with prognostic significance. This will guide surgeons in peri-operative planning and counselling as well as directing future research aimed at improving outcomes.

Cite this article: Bone Joint J 2015;97-B:134–40.

Introduction. The femoral neck in children is a common site for bone lesions. The majority are benign. However these lesions can cause diagnostic problems. Aim. To present a spectrum of chronic lesions of the femoral neck in children and emphasize the importance of tissue diagnosis. Materials and methods. Thirty two children with isolated chronic bone lesions in the femoral neck treated between 1994 and 2013were retrospectively reviewed. The ages ranged between 1–13 years. Clinical features were pain and limp. Routine blood tests, x-rays and CT scans were done in all and MRI scans in 5 cases. All diagnoses were confirmed histologically. Results. Three radiological patterns were seen: lucent or cystic in 22, infiltrative (permeative)in 2, and localized densities with nidus in 8 cases. Histologically the lesions were subacute osteomyelitis in 4, tuberculosis in 9, simple bone cyst in 7, osteoid osteoma in 7, chondroblastoma in 1, monostotic fibrous dysplasia in 2 and eosinophilic granuloma in 2 cases. Two tuberculous lesions were associated with subluxation of the hip and involvement of the head occurred in 2 others. Treatment and outcome. All lesions were curetted. Bone grafting was done in 10. Immobilisation was by internal fixation in 1, traction in 2 and spica cast in 29 cases. Follow up was 9 months to 11 years. Healing occurred in the majority. Recurrence occurred in 2 cases. Coxa vara developed in 6, and growth disturbance with shortening in 9 patients. Discussion. Femoral neck lesions are mainly benign, present diagnostic difficulty and treatment is challenging. There are problems with immobilization and of purchase with fixation devices due to poor bone stock on the neck of femur. The spica cast is a reliable method of immobilization in children under 10years. Growth disturbance and coxa vara can result after healing. CT scan is useful in assessing the architecture of the bone. NO DISCLOSURES

Introduction:. The National institute of Health and Clinical Excellence (NICE) guidelines for thromboprophylaxis following lower limb surgery and plastercast immobilisation recommend pharmacological prophylaxis be considered until the cast is removed. These guidelines have been extrapolated from data for hip and knee arthroplasty, and trauma studies. Recent studies have questioned the validity of these guidelines. At Portsmouth, low molecular weight heparin (LMWH) is prescribed for 14 days following surgery in high risk patients. The protocol predates the most recent NICE guidance. We set out to investigate whether this was a safe method of thromboprophylaxis following elective hindfoot surgery. Methods:. A retrospective audit of all patients undergoing hindfoot surgery between 01/01/10 and 31/12/12 was performed. All patients were immobilised in a POP backslab and prescribed 14 days of LMWH. All patients were reviewed at 2 weeks and converted to a full cast or boot. Immobilisation was continued for between 6 and 12 weeks. A list of all patients who had undergone investigation for deep vein thrombosis at Queen Alexandra hospital from 01/01/10 to 28/03/13 was obtained from the VTE investigation department. The two lists were cross referenced to identify any DVTs occurring following hindfoot surgery and plastercast immobilisation. Results:. During the 3 years, 197 major hindfoot operations were performed in 194 patients. Mean age was 53 years (range18-82) and 94 males with 100 females. Two patients had confirmed deep vein thromboses; 1 patient at 13 days post op while receiving LMWH prophylaxis. Conclusion:. Symptomatic VTE following elective hindfoot surgery and post operative plaster cast immobilisation in our hospital is rare. There are no randomised controlled trials to guide thromboprophylaxis regimes following hindfoot surgery. Based on our results, our protocol appears to be effective and safe

Introduction:

NICE guidelines state that every patient should be assessed for their VTE risk on admission to hospital. The aim of this study was to determine whether currently recommended risk assessment tools (Nygaard, Caprini, NICE and Plymouth) can correctly identify the patients at risk.

Most patients with a nightstick fracture of the ulna are treated conservatively. Various techniques of immobilisation or early mobilisation have been studied. We performed a systematic review of all published randomised controlled trials and observational studies that have assessed the outcome of these fractures following above- or below-elbow immobilisation, bracing and early mobilisation. We searched multiple electronic databases, related bibliographies and other studies. We included 27 studies comprising 1629 fractures in the final analysis. The data relating to the time to radiological union and the rates of delayed union and nonunion could be pooled and analysed statistically.

We found that early mobilisation produced the shortest radiological time to union (mean 8.0 weeks) and the lowest mean rate of nonunion (0.6%). Fractures treated with above- or below-elbow immobilisation and braces had longer mean radiological times to union (9.2 weeks, 9.2 weeks and 8.7 weeks, respectively) and higher mean rates of nonunion (3.8%, 2.1% and 0.8%, respectively). There was no statistically significant difference in the rate of non- or delayed union between those treated by early mobilisation and the three forms of immobilisation (p = 0.142 to p = 1.000, respectively). All the studies had significant biases, but until a robust randomised controlled trial is undertaken the best advice for the treatment of undisplaced or partially displaced nightstick fractures appears to be early mobilisation, with a removable forearm support for comfort as required.

Cite this article: Bone Joint J 2013;95-B:952–9.

Clinicians are often asked by patients, “When can I drive again?” after lower limb injury or surgery. This question is difficult to answer in the absence of any guidelines. This review aims to collate the currently available evidence and discuss the factors that influence the decision to allow a patient to return to driving. Medline, Web of Science, Scopus, and EMBASE were searched using the following terms: ‘brake reaction time’, ‘brake response time’, ‘braking force’, ‘brake pedal force’, ‘resume driving’, ‘rate of application of force’, ‘driving after injury’, ‘joint replacement and driving’, and ‘fracture and driving’. Of the relevant literature identified, most studies used the brake reaction time and total brake time as the outcome measures. Varying recovery periods were proposed based on the type and severity of injury or surgery. Surveys of the Driver and Vehicle Licensing Agency, the Police, insurance companies in the United Kingdom and Orthopaedic Surgeons offered a variety of opinions.

There is currently insufficient evidence for any authoritative body to determine fitness to drive. The lack of guidance could result in patients being withheld from driving for longer than is necessary, or returning to driving while still unsafe.

Cite this article: Bone Joint J 2013;95-B:290–4.

A comprehensive study of osteology remains a cornerstone of current orthopaedic and traumatological education. Osteology was already established as an important part of surgical education by the 16^th century. In order to teach anatomy and osteology, the corpses of executed criminals were dissected by the praelector anatomiae of the Amsterdam Guild of Surgeons. Magnificent anatomical atlases preserve the knowledge obtained from these dissections. We present an overview of the most authoritative works of Vesalius, Bidloo, Cheselden, and Albinus authored in the 16^th, 17^th and 18^th centuries. At that time a knowledge of osteology was necessary to pass the ‘master-exam’ in order to become a surgeon, and anatomical teaching was traditionally based on the practice of dissection. In the modern era, anatomical dissection and illustrations are largely being replaced by three-dimensional imaging and computer simulations, with an unfortunate trend in current curricula away from the established teaching technique of dissection. Education through the practice of dissection, particularly for future surgeons, remains integral to the development of tissue handling techniques, understanding of anatomical variation, and furthering of spatial awareness skills. With this review, we seek to remind contemporary surgeons of the lessons we can learn from our predecessors who valued education through anatomical dissection.

Aim

The purpose of this study was to investigate the effects of plaster/splint immobilisation of the knee/ankle on driving performance in healthy individuals.

Introduction

The incidence of deep venous thrombosis (DVT) in patients with lower limb cast immobilization occurs in up to 20% of patients. This may result from altered calf pump function causing venous stasis. Our aim was to determine the effects of below knee cast on calf pump function.

Bone bruising of the scaphoid is a common term reported, when MRI imaging is carried out for continued pain, within the anatomical snuff box. Is this significant? Our aim was to ascertain if bone bruising lead to continued symptoms, and resulted in delayed fracture detection- an occult fracture. This was a prospective study looking at 170 patients with scaphoid injuries. Of the 170 scaphoid injuries identified there were 120 scaphoid fractures seen on scaphoid view radiographs. The remaining 50 had no fracture on radiographs, however were clinically symptomatic and had MRI scaphoid imaging which demonstrated various grades of bone bruising. All were treated in a scaphoid plaster and re-examined at 8 weeks. There 4 were patients that remained symptomatic, MRI scan were performed which revealed 3 with resolving scaphoid bone bruising and 1 with a scaphoid fracture (p-value=0.05). Two further weeks of immobilisation resolved the symptoms of those 4 patients. Therefore occult scaphoid fractures demonstrating only bone bruising may take up to 8 weeks to declare itself as a fracture. Immobilisation in a scaphoid cast should be the mainstay of treatment for a minimum period of 8 weeks

Introduction

Peri prosthetic fracture is a recognised complication following Total ankle arthroplasty (TAA). There is limited literature on post operative management following TAA and controversies exist based on surgeon preferences. This project reports the incidence of peri- prosthetic fractures in patients managed with 2 different post-operative protocols.

Aims. To discover how the management of traumatic anterior shoulder dislocation in the young patient (17-25) has changed, if at all, over the past six years. Methods. The same postal questionnaire was sent in 2002 and 2009 to 164 shoulder surgeons. Questions were asked about initial reduction, investigation undertaken, timing of surgery, preferred stabilisation procedure, period of immobilisation and rehabilitation programme instigated in first-time and recurrent traumatic dislocators. Summary of Results. Response rate - 92% (2009), 83% (2002). The most likely management of a young traumatic shoulder dislocation:. Reduction under sedation in A&E by A&E doctor (80%). Apart from X-ray, no investigations are performed (80%). Immobilisation for 3 weeks, followed by physiotherapy (82%). 68% would consider stabilisation surgery for first time dislocators (especially professional sportsmen) compared to 35% (2002). Of them, nearly 90% would perform an arthroscopic stabilisation vs. 57.5% (2002). For recurrent dislocators:. 75% would consider stabilisation after a second dislocation. 85% would investigate prior to surgery, choice of investigation being MR arthrogram (52%), compared to 50% (2002). 77% would perform arthroscopic stabilisation vs. 18% (2002), commonest procedure-arthroscopic Bankart repair using biodegradable bone anchors (62% 2009 vs. 27% in 2002). Immobilisation for 3 weeks, full range of motion 1-2 months and return to contact sports 6 - 12 months. Conclusion. There has been a remarkable change in practice compared to the previous survey. A significant proportion of Orthopaedic Surgeons would consider stabilisation in young first-time dislocators instead of conservative management. Arthroscopic stabilisation is now the preferred technique compared to open stabilisation whenever possible. Surgeons are using more investigations prior to listing the patient for surgery, namely the MR arthrogram. There is also an increased use of bio-degradable anchors as compared to metallic bone anchors in 2002

Purpose

To investigate the effect of soft tissue release (STR) and the length of postoperative immobilisation on the long term outcomes of closed reduction (CR) of the hip for developmental dysplasia of the hip.