Aims. Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures. Methods. A systematic review and meta-analysis were performed for conservatively treated displaced midshaft clavicle fractures. Embase, PubMed, and Cochrane Central Register of Controlled Trials (via Cochrane Library) were searched from inception to 12 May 2022, with supplementary searches in Open Grey, ClinicalTrials.gov, ProQuest Dissertations & Theses, and Google Scholar. The searches were performed without limits for publication date or languages. Results. The meta-analysis included eight studies, 2,285 observations, and 304 events (nonunion). The random effects model predicted a pooled risk ratio (RR) of 3.68 (95% confidence interval 1.87 to 7.23), which can be considered significant (p = 0.003). It indicates that smoking more than triples the risk of nonunion when a fracture is treated conservatively. Conclusion. Smoking confers a RR of 3.68 for developing a nonunion in patients with a displaced middle third clavicle fracture treated conservatively. We know that most patients with pseudarthrosis will have pain and a poor functional outcome. Therefore, patients should be informed of the significantly higher risks of nonunion and offered smoking cessation efforts and counselling. Moreover, surgery should be considered for any patient who smokes with this type of fracture. Cite this article: Bone Joint J 2023;105-B(7):801–807

Aims. Proximal humeral fractures (PHFs) are common. There is increasing evidence that most of these fractures should be treated conservatively. However, recent studies have shown an increase in use of operative treatment. The aim of this study was to identify the trends in the incidence and methods of treatment of PHFs in Finland. Methods. The study included all Finnish inhabitants aged ≥ 16 years between 1997 and 2019. All records, including diagnostic codes for PHFs and all surgical procedure codes for these fractures, were identified from two national registers. Data exclusion criteria were implemented in order to identify only acute PHFs, and the operations performed to treat them. Results. During the 23-year study period, 79,676 PHFs were identified, and 14,941 operations were performed to treat them. The incidence of PHFs steadily increased. In 2019, the overall incidence was 105 per 100,000 person-years (10. 5. ). The sex-adjusted incidence for females was 147.1 per 10. 5. , and the age-adjusted incidence for patients aged ≥ 80 years was 407.1 per 10. 5. The incidence of operative treatment for PHFs rose during the first half of the study period and decreased during the second half. The use of plate osteosynthesis in particular decreased. In 2019, the incidence of operative treatment for PHFs was 13.2 per 10. 5. , with 604 operations. Conclusion. Although the incidence of PHFs is steadily increasing, particularly in elderly females, the incidence of operative treatment is now decreasing, which is in line with current literature regarding their treatment. Cite this article: Bone Joint J 2022;104-B(1):150–156

Aims. People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial). Methods. An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials. Results. There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%). Conclusion. This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK. Cite this article: Bone Jt Open 2024;5(7):612–620

Principles of bone preservation and restoration of biomechanical alignment should be followed during revision total hip arthroplasty (THA). Where possible, conservative femoral revision techniques and even reconstructive de-escalation involving using primary stems should be considered. This study aims to investigate the outcome of patients who have undergone conservative femoral revision THA in our Institution. We retrospectively identified patients from our Institution's revision arthroplasty database who had cemented, or un-cemented primary stems implanted during revision THA of a previous stemmed femoral implant. Our primary outcome measure was all-cause re-revision THA with a secondary outcome measure of improvement in Oxford hip score (OHS). Radiographic evidence of stem loosening and post-op complications were recorded. Between 02/12/2014 to 12/12/2019, there were 226 patients identified with a mean follow up of 2 years (1–5 years). The majority of cases were represented by Paprosky type 1 (63%) and type 2 (25%) femoral defects. There were 45 patients (20%) who underwent impaction bone grafting (IBG) and 43 patients (19%) who had a cement in cement (CinC) femoral revision and cemented primary stem in 137 (60%), 1 uncemented stem with no IBG or CinC revision. Kaplan Meier survival for all-cause re-revision THA was 93.7% (95% CI: 88.3 – 100) at 3 years. The reasons for re-revision included 4 periprosthetic fractures, 4 dislocations, 1 deep infection, 1 loosening of femoral component and 1 loosening of acetabular component. Pre- and post-operative OHS scores were available in 137 hips (60%) with a mean improvement of 13. Radiographic review revealed 7% of cases with evidence of loosening in 1 or more Gruen zones. Our early results support the use of conservative femoral revision THA techniques where appropriate, with low complication and re-revision rates. Revisions using primary femoral components, where appropriate, should be considered in surgical planning to avoid unnecessary reconstructive escalation

Aims. Our rural orthopaedic service has undergone service restructure during the COVID-19 pandemic in order to sustain hip fracture care. All adult trauma care has been centralised to the Royal Shrewsbury Hospital for assessment and medical input, before transferring those requiring operative intervention to the Robert Jones and Agnes Hunt Orthopaedic Hospital. We aim to review the impact of COVID-19 on hip fracture workload and service changes upon management of hip fractures. Methods. We reviewed our prospectively maintained trust database and National Hip Fracture Database records for the months of March and April between the years 2016 and 2020. Our assessment included fracture pattern (intrascapular vs extracapsular hip fracture), treatment intervention, length of stay and mortality. Results. We treated 288 patients during March and April between 2016 and 2020, with a breakdown of 55, 58, 53, 68, and 54 from 2016 to 2020 respectively. Fracture pattern distribution in the pre-COVID-19 years of 2016 to 2019 was 58% intracapsular and 42% extracapsular. In 2020 (COVID-19 period) the fracture patterns were 65% intracapsular and 35% extracapsular. Our mean length of stay was 13.1 days (SD 8.2) between 2016 to 2019, and 5.0 days (6.3) days in 2020 (p < 0.001). Between 2016 and 2019 we had three deaths in hip fracture patients, and one death in 2020. Hemiarthroplasty and dynamic hip screw fixation have been the mainstay of operative intervention across the five years and this has continued in the COVID-19 period. We have experienced a rise in conservatively managed patients; ten in 2020 compared to 14 over the previous four years. Conclusion. There has not been a reduction in the number of hip fractures during COVID-19 period compared to the same time period over previous years. In our experience, there has been an increase in conservative treatment and decreased length of stay during the COVID -19 period. Cite this article: Bone Joint Open 2020;1-8:500–507

Aims. Conservative treatment of moderately displaced proximal humeral head fractures yields good clinical results, but secondary fragment displacement may occur. Identification of those fractures at risk of displacement may influence initial decision-making. Methods. A total of 163 shoulders in 162 patients with conservatively treated isolated proximal humeral fractures were included. The fractures occurred between January 2015 and May 2018. The mean age of the patients was 69 years (26 to 100) and the mean follow-up was 144 days (42 to 779). The fractures were classified according to Neer. Scores for osteoporosis (Tingart, Deltoid Tuberosity Index (DTI)) and osteoarthritis (OA) of the glenohumeral joint were assessed. Translation of the head on follow-up radiographs of more than 10 mm was defined as displacement. Eccentric head index (EHI) describes the offset of the humeral head centre in relation to the diaphyseal axis. The ratio was estimated on anteroposterior (AP) and Neer views. Medial hinge was considered intact if the medial cortex proximal and distal to the fracture was in line on AP view. Results. Secondary fracture displacement occurred in 41 patients (25.2%). Clinical risk factors were alcohol abuse (odds ratio (OR) 6.8; 95% confidence interval (CI) 1.3 to 36; p = 0.025) and previously diagnosed osteoporosis (OR 4.6; 95% CI 0.6 to 34; p = 0.136). Age (OR 1.1; 95% CI 1.0 to 1.1; p = 0.003) and sex (OR 0.9; 95% CI 0.3 to 2.8; p = 0.867) were not independent factors. Radiological risk factors were OA grade 3 (OR 16.4; 95% CI 0.25 to 37.6; p = 0.107) and osteoporosis with the DTI (OR 10; 95% CI 0.8 to 250; p = 0.031) being more predictive than the Tingart score (OR 2.3; 95% CI 0.8 to 4.7; p = 0.041). A high EHI (AP/Neer > 0.4, OR 18.9; 95% CI 2.1 to 30.9/3.0; 95% CI 1.1 to 8.0; p = 0.002/p = 0.033) and a disrupted medial hinge (OR 3.7; 95% CI 1.1 to 12.6; p = 0.039) increased the risk of secondary displacement significantly. Neer classification had no influence. Conclusion. During conservative treatment, a quarter of patients showed secondary fracture displacement of at least 10 mm. Patients with alcohol abuse, severe OA, and osteoporosis are at risk. Newly defined EHI and disrupted medial hinge are relevant predictors for secondary displacement. Cite this article: Bone Joint J 2020;102-B(7):881–889

Aims. The aim of the present study was to answer the question whether curve morphology and location have an influence on rigid conservative treatment in patients with adolescent idiopathic scoliosis (AIS). Methods. We retrospectively analyzed AIS in 127 patients with single and double curves who had been treated with a Chêneau brace and physiotherapeutic specific exercises (B-PSE). The inclusion criteria were the presence of structural major curves ≥ 20° and < 50° (Risser stage 0 to 2) at the time when B-PSE was initiated. The patients were divided into two groups according to the outcome of treatment: failure (curve progression to ≥ 45° or surgery) and success (curve progression < 45° and no surgery). The main curve type (MCT), curve magnitude, and length (overall, above and below the apex), apical rotation, initial curve correction, flexibility, and derotation by the brace were compared between the two groups. Results. In univariate analysis treatment failure depended significantly on: 1) MCT (p = 0.008); 2) the apical rotation of the major curve before (p = 0.007) and during brace treatment (p < 0.001); 3) the initial and in-brace Cobb angles of the major (p = 0.001 and p < 0.001, respectively) and minor curves (p = 0.015 and p = 0.002); 4) major curve flexibility (p = 0.005) and the in-brace curve correction rates (major p = 0.008, minor p = 0.034); and 5) the length of the major curve (LoC) above (p < 0.001) and below (p = 0.002) the apex. Furthermore, MCT (p = 0.043, p = 0.129, and p = 0.017 in MCT comparisons), LoC (upper length p = 0.003, lower length p = 0.005), and in-brace Cobb angles (major p = 0.002, minor p = 0.027) were significant in binary logistic regression analysis. Conclusion. Curve size, location, and morphology were found to influence the outcome of rigid conservative treatment of AIS. These findings may improve future brace design and patient selection for conservative treatment. Cite this article: Bone Joint J 2021;103-B(2):373–381

Aims. The purpose of this study was to compare the effectiveness of surgical repair to conservative treatment and subacromial decompression for the treatment of chronic/degenerative tears of the rotator cuff. Materials and Methods. PubMed, Cochrane database, and Medline were searched for randomized controlled trials published until March 2018. Included studies were assessed for methodological quality, and data were extracted for statistical analysis. The systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results. Six studies were included. Surgical repair resulted in a statistically significantly better Constant–Murley Score (CMS) at one year compared with conservative treatment (mean difference 6.15; p = 0.002) and subacromial decompression alone (mean difference 5.81; p = 0.0004). In the conservatively treated group, 11.9% of patients eventually crossed over to surgical repair. Conclusion. The results of this review show that surgical repair results in significantly improved outcomes when compared with either conservative treatment or subacromial decompression alone for degenerative rotator cuff tears in older patients. However, the magnitude of the difference in outcomes between surgery and conservative treatment may be small and the ‘success rate’ of conservative treatment may be high, allowing surgeons to be judicious in choosing those patients who are most likely to benefit from surgery. Cite this article: Bone Joint J 2019;101-B:1100–1106

Aims. The primary aim of this study was to assess if traumatic triangular fibrocartilage complex (TFCC) tears can be treated successfully with immobilization alone. Our secondary aims were to identify clinical factors that may predict a poor prognosis. Methods. This was a retrospective analysis of 89 wrists in 88 patients between January 2015 and January 2019. All patients were managed conservatively initially with either a short-arm or above-elbow custom-moulded thermoplastic splint for six weeks. Outcome measures recorded included a visual analogue scale for pain, Patient-Rated Wrist Evaluation, Disabilities of the Arm, Shoulder and Hand score, and the modified Mayo Wrist Score (MMWS). Patients were considered to have had a poor outcome if their final MMWS was less than 80 points, or if they required eventual surgical intervention. Univariate and logistic regression analyses were used to identify independent predictors for a poor outcome. Results. In total, 76% of wrists (42/55) treated with an above-elbow splint had a good outcome, compared to only 29% (10/34) with a short-arm splint (p < 0.001). The presence of a complete foveal TFCC tear (p = 0.009) and a dorsally subluxated distal radioulnar joint (DRUJ) (p = 0.032) were significantly associated with a poor outcome on univariate analysis. Sex, age, energy of injury, hand dominance, manual occupation, ulnar variance, and a delay in initial treatment demonstrated no significant association. Multiple logistic regression revealed that short-arm immobilization (p < 0.001) and DRUJ subluxation (p = 0.020) were significant independent predictive factors of an eventual poor outcome. Conclusion. Nonoperative management of traumatic TFCC injuries with above-elbow immobilization is a viable treatment method, particularly in patients without DRUJ subluxation. Early surgery should be considered for patients with dorsal ulnar subluxation treated with short-arm splints to prevent prolonged morbidity. Cite this article: Bone Joint J 2021;103-B(8):1386–1391

Background and Purpose. The UK's NIHR and Australia's NHMRC have funded two randomised controlled trials (RCTs) to determine if lumbar fusion surgery (LFS) is more effective than best conservative care (BCC) for adults with persistent, severe low back pain (LBP) attributable to lumbar spine degeneration. We aimed to describe clinicians’ decision-making regarding suitability of patient cases for LFS or BCC and level of equipoise to randomise participants in the RCTs. Methods. Two online cross-sectional surveys distributed via UK and Australian professional networks to clinicians involved in LBP care, collected data on clinical discipline, practice setting and preferred care of five patient cases (ranging in age, pain duration, BMI, imaging findings, neurological signs/symptoms). Clinicians were also asked about willingness to randomise each patient case. Results. Of 174 responses (73 UK, 101 Australia), 70 were orthopaedic surgeons, 34 neurosurgeons, 65 allied health professionals (AHPs), 5 others. Most worked in public health services only (92% UK, 45% Australia), or a mix of public/private (36% Australia). Most respondents chose BCC as their first-choice management option for all five cases (81–93% UK, 83–91% Australia). For LFS, UK surgeons preferred TLIF (36.4%), whereas Australian surgeons preferred ALIF (54%). Willingness to randomise cases ranged from 37–60% (UK mean 50.7%), and 47–55% (Australian mean 51.9%); orthopaedic and neuro-surgeons were more willing than AHPs. Conclusion. Whilst BCC was preferred for all five patient cases, just over half of survey respondents in both the UK and Australia were willing to randomise cases to either LFS or BCC, indicating clinical equipoise (collective uncertainty) needed for RCT recruitment. Conflicts of interest. None. Sources of funding. No specific funding obtained for the surveys. DB, SA, AG and NEF have funding from the National Institute for Health Research (NIHR) UK (FORENSIC-UK NIHR134859); NEF, DB and SA have funding from the Australian National Health and Medical Research Council (NHMRC FORENSIC-Australia GA268233). AG has funding from Orthopaedic Research UK (combined with British Association of Spine Surgeons and British Scoliosis Society) and Innovate UK. NEF is funded through an Australian National Health and Medical Research Council (NHMRC) Investigator Grant (ID: 2018182)

Thumb carpometacarpal (CMC) arthritis is a common and disabling condition that can be treated with an operative procedure. Before operative measures, patients typically undergo conservative treatment utilizing methods such as physical therapy and injections. This study aims to determine what clinical modalities are being used for preoperative evaluation and nonoperative therapy and the associated cost prior to operative intervention. We queried Truven Market Scan, a large insurance provider database to identify patients undergoing CMC arthroplasty from 2010 to 2017. Patients were identified by common Current Procedural Terminology (CPT) codes for CMC arthroplasty. All associated CPT codes listed for each patient during the 1 year period prior to operative intervention were collected and filtered to only include those codes associated with the ICD-9/10 diagnosis codes relating to CMC arthritis. The codes were then categorized as office visits, x-ray, injections, physical therapy, medical devices, and preoperative labs. The frequency and associated cost for each category was determined. There were 44,676 patients who underwent CMC arthroplasty during the study period. A total of $26,319,848.36 was charged during the preoperative period, for an average of $589.13 per patient. The highest contributing category to overall cost was office visits (42.1%), followed by injections (13.5%), and then physical therapy (11.1%). The most common diagnostic modality was x-ray, which was performed in 74.7% of patients and made up 11.0% of total charges. Only 49% of patients received at least one injection during the preoperative period and the average number of injections per patient was 1.72. Patients who were employed full time were more likely to receive two or more injections prior to surgery compared to patients who had retired (47% of full-time workers; 34% of retirees). The modalities used for the preoperative evaluation and conservative treatment of CMC arthritis and the associated cost are important to understand in order to determine the most successful and cost-effective treatment plan for patients. Surprisingly, despite the established evidence supporting clinical benefits, many patients do not undergo corticosteroid injections. With office visits being the largest contributor to overall costs, further inquiry into the necessity of multiple visits and efforts to combine visits, can help to reduce cost. Also, with the advent of telemedicine it may be possible to reduce visit cost by utilizing virtual medicine. Determining the best use of telemedicine and its effectiveness are areas for future investigation

Osteoporotic vertebral compression fractures (VCFs) are an increasing public health problem. Recently, randomised controlled trials on the use of kyphoplasty and vertebroplasty in the treatment of these fractures have been published, but no definitive conclusions have been reached on the role of these interventions. The major problem encountered when trying to perform a meta-analysis of the available studies for the use of cementoplasty in patients with a VCF is that conservative management has not been standardised. Forms of conservative treatment commonly used in these patients include bed rest, analgesic medication, physiotherapy and bracing. . In this review, we report the best evidence available on the conservative care of patients with osteoporotic VCFs and associated back pain, focusing on the role of the most commonly used spinal orthoses. Although orthoses are used for the management of these patients, to date, there has been only one randomised controlled trial published evaluating their value. Until the best conservative management for patients with VCFs is defined and standardised, no conclusions can be drawn on the superiority or otherwise of cementoplasty techniques over conservative management

Background. Bacteriophages are natural viruses of interest in the field of PJI. A paper previously reported the PhagoDAIR procedure (use of phages during DAIR) in three patients with PJI for whom explantation was not desirable. As the need to isolate the pathogen before surgery to perform phage susceptibility testing is a strong hindrance for the development of this procedure, we developed post-operative phage injections using ultrasound, in patients infected with S. aureus and/or P. aeruginosa who were eligible for the PhagoDAIR procedure, but for whom phages were not available at the time of surgery. Materials/Methods. We performed a single center, exploratory, prospective cohort study including patients with knee PJI who received phage therapy with ultrasound after performance of a DAIR or a partial prosthesis exchange. All patients had PJI requiring conservative surgery and suppressive antimicrobial therapy (SAT) as salvage procedure. Each case was discussed in multidisciplinary meetings in agreement with French health authority, based on the clinical presentation, and the phage susceptibility testing. The cocktail of highly concentrate active phages (5 mL; about 10. e. 9 PFU/mL) was extemporaneous prepared and administered three times directly into the joint using sonography (1 injection per week during 3 weeks) during the postoperative period, before switching antibiotics to SAT. Results. Seven patients received phages under sonography after the DAIR, and one after a partial exchange (mean age 71 years). All had resection prosthesis or constrained knee prosthesis. Among these seven patients, three were infected with S. aureus (including one MRSA), two were infected with P. aeruginosa (one was a multidrug-resistant isolate), one was infected with both S. aureus and P. aeruginosa and the last one was infected with MRSA, S. epidermidis and Corynebacterium spp.. All patients received a cocktail of active phages provided by Pherecydes Pharma targeting S. aureus or P. aeruginosa. No adverse event was recorded during or after the local injections. All patients were switched to SAT after a primary postoperative antimicrobial therapy of three months. Under SAT, the patient with S. epidermidis co-infection developed a relapse due to the S. epidermidis. With a mean follow-up of 13 months after surgery (from 9 to 24 months), the outcome was favorable for all patients without any sign of infection; none of them had abnormal pain, joint effusion or loosening. Conclusions. Postoperative administration of phages using sonography is a potentially useful procedure in patients with complex PJI for whom a conservative approach is desirable

Arthritis of the mid-foot is a common presentation to the foot and ankle clinic, resulting from primary (idiopathic), post-traumatic, or inflammatory joint degeneration. Treatment in the initial stages is conservative, with midfoot fusion regarded as the operative treatment of choice; however there is a paucity of comparative and patient reported data regarding outcomes. Patient reported outcome measures (PROMS), were prospectively collected from October-2015 to March-2018. Diagnoses were confirmed with image guided injection and initial management was conservative. In total, 66 patients were managed conservatively and 40 treated with mid-foot fusion. MOxFQ (Manchester Oxford Foot Questionnaire) and EQ-5D-3L (Euroqual) PROMS were collected pre-operatively, at 26 weeks and at 52 weeks. In the operatively managed group, the female:male ratio was 5.7:1, with a mean age of 61 (range 24–80), while in the conservatively managed group, the ratio was 2.1:1 with mean age 63 (range 29–86). In the surgically managed group, 88.2% of patients reported improvement in symptoms at 26 weeks and 88.9% at 52 weeks. This was greater than the conservatively managed group, in which 40.6% reported improvement at 26 weeks and 33.3% at 52 weeks. Mean MOxFQ improvement in the surgically managed group was +30.7 and +33.9 at 26 and 52 weeks respectively, and in the conservative group, +9.4 and +4.3, at 26 and 52 weeks. Similarly, favourable surgical outcomes were reported across all domains of EQ-5D-3L. This study has highlighted excellent early outcomes after surgical treatment and may represent promise for those patients for whom conservative management fails

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 nonoperatively for acetabular fractures.

It has been noted that bony union of a pars defect can be achieved in children if they wear a trunk brace. Our aim was to evaluate how the stage of the defect on CT and the presence or absence of high signal change in the adjacent pedicle on T2-weighted MRI were related to bony healing. We treated 23 children conservatively for at least three months. There were 19 boys and four girls with a mean age of 13.5 years (7 to 17). They were asked to refrain from sporting activity and to wear a Damen soft thoracolumbosacral type brace. There were 41 pars defects in 23 patients. These were classified as an early, progressive or terminal stage on CT. The early-stage lesions had a hairline crack in the pars interarticularis, which became a gap in the progressive stage. A terminal-stage defect was equivalent to a pseudarthrosis. On the T2-weighted MR scan the presence or absence of high signal change in the adjacent pedicle was assessed and on this basis the defects were divided into high signal change-positive or -negative. Healing of the defect was assessed by CT. In all, 13 (87%) of the 15 early defects healed. Of 19 progressive defects, only six (32%) healed. None of the seven terminal defects healed. Of the 26 high signal change-positive defects 20 (77%) healed after conservative treatment whereas none of the high signal change-negative defects did so. We concluded that an early-stage defect on CT and high signal change in the adjacent pedicle on a T2-weighted MR scan are useful predictors of bony healing of a pars defect in children after conservative treatment

Optimal management of acute patellar dislocation is still a topic of debate. Although, conventionally it has been managed by non-operative measures, recent literature recommends operative treatment to prevent re-dislocations. Our study recommends that results of non-operative measures comparable to that of operative management. Our study is the retrospective with 46 consecutive patients (47 knees) of first time patellar dislocation managed between 2012 and 2014. The study methodology highlighted upon the etiology, mechanism of injury and other characteristics of first time dislocations and also analysed outcomes of conservative management including re-dislocation rates. The duration of follow up ranged from 1 to 4 years. Average age at first-time dislocation was 23 years (Range 10–62 years). Male:Female ratio was 30:17. Twisting injury was the commonest cause. 1 patient required open reduction but all others relocated spontaneously or had successful closed reduction. Medial Patello-Femoral Ligament injury was frequent associated feature. 11 knees (24%) re-dislocated during follow up. Age was the significant risk factor for re-dislocations. All patients with re-dislocation were less than 30 years old. Maximum redislocations happened between 6 months to 1 year after index dislocation. Skeletal abnormality was the commonest pathology in re-dislocators. Only 4 patients (8.6%) finally required surgical intervention. One patient had persistent knee pain as a complication. Conservative management of primary patellar dislocation is successful in majority of patients. Surgery should be reserved for the carefully selected patients with specific indications

The best management for acute rupture of the Achilles tendon remains controversial. An unacceptably high re-rupture rate following conservative management has been quoted as a reason for surgical management, however, many of these studies do not stand up to critical scrutiny. Since 1989 I have personally treated over 1600 consecutive patients with acute rupture of the tendo-achilles using a conservative functional management protocol. This protocol was developed in the light of experience over a number of years. I will present an independent review of 1044 consecutive patients presenting to my tendo-achilles clinic between 1996 and 2008. After examination, 975 patients were found to have an acute tendon rupture, the rest being gastrocnemius muscle tears, painful Achilles tendonopathy or mis-referrals. Of these 975 patients 29 were late presenters in whom the tendon ends did not approximate well on plantar flexion. These patients were therefore treated surgically. One patient was too obese to be included in the standard protocol, although he was still treated conservatively. With a minimum follow up of two years, the overall re-rupture rate was 2.9%. The re-rupture rate using this management protocol is similar to or better than the published operative re-rupture rates. The protocol, complications and outcome will be discussed and I recommend a well defined and tested non operative functional management protocol for treatment of acute tendo-achilles rupture. This protocol is suitable for all ages including those with significant sporting demands. It is essential that patients have assessment and follow up carried out by a senior and experienced surgeon

Patients presenting with arthrosis following high tibial osteotomy (HTO) pose a technical challenge to the surgeon. Slight overcorrection during osteotomy sometimes results in persisting medial unicompartmental arthrosis, but with a valgus knee. A medial UKA is desirable, but will result in further valgus deformity, while a TKA in someone with deformity but intact cruciates may be a disappointment as it is technically challenging. The problem is similar to that of patients with a femoral malunion and arthrosis. The surgeon has to choose where to make the correction. An ‘all inside’ approach is perhaps the simplest. However, this often means extensive release of ligaments to enable ‘balancing’ of the joint, with significant compromise of the soft tissues and reduced range of motion as a consequence. As patients having HTO in the first place are relatively high demand, we have explored a more conservative option, based upon our experience with patient matched guides. We have been performing combined deformity correction and conservative arthroplasty for 5 years, using PSI developed in the MSk Lab. We have now adapted this approach to the failed HTO. By reversing the osteotomy, closing the opening wedge, or opening the closing wedge, we can restore the obliquity of the joint, and preserve the cruciate ligaments. Technique: CT based plans are used, combined with static imaging and on occasion gait data. Planning software is then used to undertake the arthroplasty, and corrective osteotomy. In the planning software, both tibial and femoral sides of the UKA are performed with minimal bone resection. The tibial osteotomy is then reversed to restore joint line obliquity. The placing of osteotomy, and the angling and positioning in relation to the tibial component are crucial. This is more important in the opening of a closing wedge, where the bone but is close to the keel cut. The tibial component is then readjusted to the final ‘Cartier’ angle. Patient guides are then made. These include a tibial cutting guide which locates both the osteotomy and the arthroplasty. At operation, the bone cuts for the arthroplasty are made first, so that these cuts are not performed on stressed bone. The cuts are not in the classical alignment as they are based upon deformed bone so the use of patient specific guides is a real help. The corrective osteotomy is then performed. If a closing wedge is being opened, then a further fibular osteotomy is needed, while the closing of an opening wedge is an easier undertaking. Six cases of corrective osteotomy and partial knee replacement are presented. In all cases, the cruciates have been preserved, together with normal patello-femoral joints. Patient satisfaction is high, because the deformity has been addressed, restoring body image. Gait characteristics are those of UKA, as the ACL has been preserved and joint line obliquity restored

Introduction and Aims: To establish how effective conservative treatment is for rotator cuff impingement. To look at the clinical presentation and the factors that influences the outcome. Method: A retrospective study of 189 patients, who attended the Upper Limb Clinic, was done. The response to physiotherapy and cortisone injections was noted. We also looked at the shape of the acromion and tried to correlate it with effectiveness of conservative treatment. Results: All patients had either a positive Neer or Hawkins sign. What is more significant is that in 123 patients internal rotation was markedly restricted to the 10. th. dorsal vertebrae or less. One hundred and nineteen patients received a sub-acromial cortisone injection. It was repeated in 52 patients, and 25 patients received a third injection. Forty-four patients needed surgery. Therefore, conservative treatment was effective in 83% of cases. Of the group who was operated on, only nine patients had a large spur and only 12 patients had a Bigliani Type-III acromion. It does not seem as if the spur is the main cause for impingement. Conclusion: Conservative treatment is very effective in the treatment of rotator cuff impingement. However, we believe that the right exercise program is of essence. Stretching the posterior capsule of the shoulder joint and increasing the internal rotation, which are the two most important initial exercises, should be concentrated on. Thereafter the depressor muscles, like sub-scapularis and infra-spinatus must be strengthened

Our retrospective study of 189 patients aimed to establish the efficacy of conservative treatment for rotator cuff impingement and also to assess the clinical presentation and the factors that influence the outcome. We noted patients’ response to physiotherapy and cortisone injections. We looked at the shape of the acromion and tried to correlate it with effectiveness of conservative treatment. All patients had either a positive Neer or Hawkins sign. In 123 patients internal rotation was markedly restricted. Subacromial cortisone injections were administered to 119 patients. The injection was repeated once in 52 patients and twice in 25. Surgery was necessary in 44 patients. In other words, conservative treatment was effective in 83%. Only 12 of the patients who underwent surgery had a Bigliani type-III acromion and only nine had a large spur. An appropriate exercise programme is critical if conservative treatment is to be effective. It should focus first on stretching the posterior capsule of the shoulder joint and increasing internal rotation, and subsequently on strengthening the subscapularis and infraspinatus muscles. We believe it is the imbalance of muscle power rather than the acromial spur that is the major cause of impingement

Distal radius fractures (DRF) are common and the indication for surgical treatment remain controversial in patients higher than 60 years old. The purpose of the study was to review and analyze the current evidence-based literature. We performed a systematic review and meta-analysis according to PRISMA guidelines in order to evaluate the efficacy of volar locking plating (VLP) and conservative treatment in DRF in patients over 60 years old. Electronic databases including MEDLINE, CENTRAL, Embase, Web of science and Clinical Trial.gov were searched from inception to October 2020 for randomized controlled trials. Relevant article reference lists were also passed over. Two reviewers independently screened and extracted the data. Main outcomes included functional status: wrist range of motion, validated scores and grip strength. Secondary outcomes include post-operative complications and radiologic assessment. From 3009 screened citations, 5 trials (539 patients) met the inclusion criteria. All trials of this random effect meta-analysis were at moderate risk of bias due to lack of blinding. Differences in the DASH score (MD −5,91; 95% CI, −8,83; −3,00), PRWE score (MD −9.07; 95% CI, −14.57, −3.57) and grip strength (MD 5,12; 95% CI, 0,59-9,65) were statistically significant and favored VLPs. No effect was observed in terms of range of motion. Adverse events are frequent in both treatment groups, reoperation rate is higher in the VLP group. VLP may provide better functional outcomes in patients higher than 60 years old. More RCT are still needed to evaluate if the risks and complications of VLP outweigh the benefits

Objectives: To report the outcome and comparison of calcaneum fracture managements for intra-articular fractures. Methods: A prospective study of the patients with intra-articular calcaneum fractures in the foot& ankle unit of a busy trauma hospital. All the patients were followed up with the calcaneal fracture score. We compared the outcome of surgical management Sanders type-2 and type-3 fractures with conservative treatment at 2 years and then, the medium term (> 5 years) outcomes of type-2 and type-3 surgical groups were assessed. Conservative group was a consecutive series of patients recruited to the study later than surgical groups, hence the smaller number in that group. Results: 126 patients were included in our study. There were 70 in group type-2 and 38 in group type-3 with surgical management, while only 18 in the group with conservative management. The mean age for surgical type-2 = 46.2, type-3= 46.3 and conservative group = 51.7. Mean follow-ups for the groups were type-2=6y, type-3 =5.5y and conservative one =2.34y. Mean two-year scores for the surgical groups were type-2=68.13, type-3=63.78, while conservative one =51.36. There was a statistically significant differences in their score between type-2 surgical and conservative groups (P=0.0006), and between type-3 surgical and conservative ones (P=0.04), but no significant difference between type-2 and type-3 surgical groups. At medium-term follow-up, the scores for type-2 and type-3 surgical groups were 77.06 and 63.66 respectively, with significant increase in type-2 while type-3 remains similar comparing to two-year scores. There were 7 deep, 5 superficial infections and 32 metalwork removals in total. Conclusion: On comparing the medium term outcome to the two-year one, surgical type-2 group of patients showed some improvement, while type-3 stayed the same. In this series, contrary to published articles, there was a better outcome at two years with surgical treatment than conservative treatment

Introduction. The incidence of spondylolysis is estimated about 5–6% in the general population and accounts for one of the most frequent cause of backpain in the adolescent. The purpose of this study is to present our results from the management of these patients. Patients and Methods. During the period 1993–2003, 25 children with spondylolysis and spondylolisthesis were managed in our department. Apart from radiographic studies, in cases with a history of acute trauma, a bone scan as well as a CT or MRI scan were performed. There were 13 male and 12 female patients with a mean age of 10.5 years (5–14 years). There were 15 cases of spondylolysis, one at L3 level, 3 at L4 and 11 at L5. 10 patients had spondylolisthesis, 8 of the isthmic type and 2 of the dysplastic type. THe mean follow up of the patients was 6.5 years. Results. In 24 cases the management was conservative with bedrest until the symproms subsided. Following symptoms resolution a brace was fitted, depending on the case, for 3–6 months. In one case of Grade II spondylolisthesis with nerve root irritation a posterolateral arthrodesis according to Wiltse was performed, following failure of a prolonged period of conservative management. The results of our patients were evaluated clinically and radiologically according to Seitsalo et al and they were in all cases excellent or good, with full return of the affected children to their previous activities. Conclusion. In conlusion, spondylolysis and spondylolisthesis is managed conservative in children with good results. Rarely in cases were the symptoms persist despite conservative management, surgical treatment can provide a good result

Distal radius fractures (DRF) are common and the indication for surgical treatment remain controversial in patients higher than 60 years old. The purpose of the study was to review and analyze the current evidence-based literature. We performed a systematic review and meta-analysis according to PRISMA guidelines in order to evaluate the efficacy of volar locking plating (VLP) and conservative treatment in DRF in patients over 60 years old. Electronic databases including MEDLINE, CENTRAL, Embase, Web of science and Clinical Trial.gov were searched from inception to October 2020 for randomized controlled trials. Relevant article reference lists were also passed over. Two reviewers independently screened and extracted the data. Main outcomes included functional status: wrist range of motion, validated scores and grip strength. Secondary outcomes include post-operative complications and radiologic assessment. From 3009 screened citations, 5 trials (539 patients) met the inclusion criteria. All trials of this random effect meta-analysis were at moderate risk of bias due to lack of blinding. Differences in the DASH score (MD −5,91; 95% CI, −8,83; −3,00), PRWE score (MD −9.07; 95% CI, −14.57, −3.57) and grip strength (MD 5,12; 95% CI, 0,59-9,65) were statistically significant and favored VLPs. No effect was observed in terms of range of motion. Adverse events are frequent in both treatment groups, reoperation rate is higher in the VLP group. VLP may provide better functional outcomes in patients higher than 60 years old. More RCT are still needed to evaluate if the risks and complications of VLP outweigh the benefits

Treatment of acute Achilles tendon rupture is based on obtaining and maintaining apposition of the ruptured tendon ends. Surgical treatment utilises direct suture repair to produce this objective, while conservative or non-surgical management achieves the same effect of closing the tendon gap by immobilisation of the ankle joint in a plantar flexed position within a plaster cast or POP. There is still variability in the conservative treatment practices and protocols of acute Achilles tendon ruptures. The purpose of this study is to examine the current practice trends in the treatment of Achilles tendon ruptures amongst orthopaedic surgeons in the UK. A postal questionnaire was sent to 221 orthopaedic consultants in 25 NHS hospitals in the Greater London area in June 2010. Type and duration of immobilisation were considered along with the specifics of the regime used. Ninety questionnaires were returned giving a 41% response rate. Conservative treatment methods were used by 72% of respondents. A below knee plaster was the top choice of immobilisation (83%) within this group. The mean period of immobilisation was 9.2 weeks (Range 4-36). Weight bearing was allowed at a mean of 5.3 weeks (range 0-12). The specific regime used by consultants was quite heterogeneous across the group, however the most used immobilisation regimen was a below knee plaster in equinus with 3 weekly serial plaster changes to a neutral position, for a total of nine weeks. A heel raise after plaster removal was favoured by 73% of respondents used for a mean period of 6.4 weeks (Range 2-36). In response to ultrasound use as a diagnostic tool, 42.4% of respondents would never use it, 7.6% would use it routinely, while 50% would use it only according to the clinical situation. Comparison of foot and ankle specialists with non-specialists did not reveal a significant difference in practice in duration of immobilisation or time to bearing weight. Conservative management remains a widely practice option in the treatment of Achilles tendon ruptures. Although there are available a number of modern walking aids, the concept of functional brace immobilisation is not as widely used as below knee plaster cast immobilisation, which remains a popular choice amongst orthopaedic surgeons today. There is still no consensus on the ideal immobilisation regimen although a below knee plaster in equinus with serial changes for a total of nine weeks is the most frequently used choice. Further randomised controlled trials are required to establish the optimal treatment strategy for conservative management of Achilles tendon rupture

Introduction. Because it typically afflicts older patients with poorer health and/or risk factors, spondylodiscitis can become life threatening. Lingering symptoms, which can be attributed to residual destruction as well as concurrent degenerative changes in the adjacent segments after inflammation has subsided, are frequently present after both conservative and operative therapies. Here, quality of life outcomes are presented for patients two years after operative and conservative treatment. Methods. 82 patients with spondylodiscitis were included prospectively from 01/2008. 28% of patients were treated conservatively (Group 1) and 72% operatively (Group 2). Clinical findings, SF-36, ODI, COMI, and a visual analog scale (VAS) were evaluated and compared between the groups at admission and follow-up (2 year FU). Results. Average patient age was 64.9 ± 6.3 years. Average inpatient hospital stay was 26.5 ± 16.9 days. Neurologic deficits were present in 39.0% of patients preoperatively and 18.3% at FU. Abscess formation was diagnosed in 89.0% of cases and intraspinal abscesses in 43.9%. Hospital mortality was 11.0% and total mortality 14.6% at FU. 6.1% of cases were lost to FU. The preoperative ODI scores averaged 75.4 ± 16.6, and did not vary significantly between the groups. At FU, with 33.9 ± 21.2, average score was significantly better (p<0.001). On the SF-36, preoperative average scores were PCS 25.7 ± 7.1 and MCS 37.3 ± 13.4, and at FU PCS 43.5 ± 10.1 (p<0.05) and MCS 47.7 ± 14.8 (p<0.05). COMI scores also showed significant (p<0.001) improvement (preoperatively 9.2 ± 1.0 and at FU 3.5 ± 2.2). On comparison, patients in Group 2 (VAS 8.3) preoperatively had more pain (p<0.05) than those in Group 1 (VAS 6.3), but there was no significant difference at FU (group 2 VAS 2.5 and group 1 VAS 3.0). Over 90% of operated patients reported that treatment helped, while over 30% of conservatively treated patients said that treatment helped a little or not at all. Discussion. In the pre-antibiotics era, the prognosis for spondylodiscitis was poor. Currently, it can still lead to serious health problems and become life threatening. Quality of life and physical limitations are markedly worse than for the general population. Compared to patients treated conservatively, patients treated with surgery have somewhat improved quality of life and significantly better patient satisfaction

Purpose: The purpose of this study was to evaluate total hip arthroplasty in the treatment of post-traumatic arthritis following acetabular fracture and to compare the long-term outcome of THA after previous open reduction and internal fixation or conservative treatment of the acetabular fracture. Methods: Thirty-four patients (thirty-six hips) underwent total hip arthroplasty for arthritis resulting from an acetabular fracture. The mean age at the time of hip arthroplasty was 49 years. The mean follow-up was eight years and nine months (range, 4–17 years). The mean interval from fracture to arthroplasty was 7.5 years (range, 5 months-29 years). Twenty-three hips had been previously treated by open reduction and internal fixation and 12 hips had a conservatively treated fracture. An uncemented arthroplasty was performed in 31 hips, cemented arthroplasty in 2 patients and a hybrid replacement in 2 patients. Results: Only 16 patients achieved and maintained a good to excellent result over the course of the follow-up. The mean Harris hip score improved from 44.5 points preoperatively to 72.76 points for operatively treated fractures (23 patients). The mean Harris hip score improved from 44.2 points preoperatively to 78.7 points for conservatively treated fractures (12 patients) (p> 0.05). Ten out of 35 hips required revision; 9 were revised because of aseptic loosening and one for infection with a total revision rate of 29%. Femoral bone quality was significant in predicting revision. No femoral radiographic loosening was found at latest follow-up. On the acetabular side, the rate of radiographic loosening was higher. There was no significant difference in bone grafting, heterotopic bone formation, revision rate, operative time and blood loss between the two groups (ORIF vs conservative treatment of acetabular fracture) (p> 0.05). Conclusions: Outcome following total hip arthroplasty in the treatment of post-traumatic arthritis following acetabular fracture is less favourable than following primary osteoarthritis. Those patients initially treated conservatively had similar long term results compared to those treated primarily by open reduction and internal fixation. At long term follow-up, the main problem identified was osteolysis and acetabular wear

Purpose: The objective of this study was to analyze and compare the results obtained after 2 types of treatment, surgical and conservative, for acute patellar dislocations. Methods: We divided 33 patients with acute patellar dislocations into 2 groups. One group with 16 patients underwent conservative treatment (immobilization and subsequent physiotherapy), and the other group with 17 patients underwent surgical treatment. A radiographic examination was performed in the evaluation of the patients to verify predisposing factors for patellofemoral instability, and the Kujala questionnaire was applied with the intention of analyzing the improvement of pain and quality of life. The 2 test, t test, and Fisher test were used in the statistical evaluation. A significance level of P.05 was adopted. Results: The groups were considered parametric in relation to age and sex. The conservative treatment group exhibited a higher number of recurrent dislocations (8 patients) than the surgical treatment group, which did not have any relapses. In addition, the surgical treatment group obtained a better mean score on the Kujala test (92) than the conservative treatment group (69). Conclusions: We conclude that surgical treatment afforded better results. There were no recurrences in the surgical treatment group, but there were 8 recurrences in the conservative treatment group. The mean Kujala score was 92 in the surgical treatment group and 69 in the conservative treatment group. Level of Evidence: Level II, lesser-quality therapeutic randomized controlled trial. Key Words: Patellofemoral— Dislocation—Recurrences—Medial patellofemoral ligament—Knee

Knee osteoarthritis (OA) is a major cause of pain and disability in elder people. The prevalence of radiographic OA in a population aged 35–74 years is 5–15% and about one third of involved people complain of symptoms. In the „Ulm Osteoarthritis Study“ patients undergoing total knee replacement reported a mean duration of knee pain of 10 years prior to surgery. Multiple genetic, constitutional and environmental factors contribute to the development of OA. Initial cartilage degradation leads to joint space narrowing and early osteophyte formation which can be observed radiographically. Whether elevated subchondral bone mineral density is contributing to manifestation of the disease or just a secondary reaction process is still under debate. OA finally involves not only cartilage and subchondral bone but also soft tissues in and around the joint (synovial membrane, ligaments and muscles), which often results in painful effusions, muscular shortening and stiffness. Many conservative treatment options have been developed in the past to relief these symptoms and to slow down or even stop the cartilage degradation process. Evidence to support the effectiveness of individual treatments, however, is variable. Recently the EULAR Committee for Clinical Trials determined an approach for the development of evidence based guidelines for conservative treatment of knee OA (. Pendleton et al, . Ann Rheum Dis. 2000. ;. 59. :. 936. –944. ). Through a process of quality assessment of available publications and determination of expert consensus employing a Delphi approach propositions relating to a rationale conservative management could be made:. Treatment of knee OA must be tailored to individual patients, taking into account factors such as age, comorbidity and the presence of inflammation. Optimal management requires a combination of non-pharmacological treatment modalities (regular education, exercise, appliances and weight reduction) and pharmacological approaches. Paracetamol generally is the preferred analgesic and there is enough evidence to support its application, as the pain controlling effects are comparable to NSAIDS and long term application is safe enough. NSAIDS (oral or even topical) can be considered in patients with effusion. Although some studies found NSAIDS to have better efficacy than paracetamol in the treatment of painful knee OA, the gastrointestinal side effects limit their long-term application. Therefore most experts consider their application only in patients unresponsive to paracetamol and in major effusions. In such situations long-acting steroids can be injected intra-articularly as well. While the effects of steroids in knee OA have been assessed in a number of studies, the predictors of response are still somewhat unclear and further investigations are necessary. Recent data seems to support the theory that some symptomatic slow acting drugs (glucosamine sulfate, chondroitin sulfate, diacerein and hyaluronic acid) may possess structure modifying properties. Further studies, however, are necessary to determine the pharmacoeconomic aspects of that treatment and to define the indications more precisely. Education should be an integral part in the management of knee OA. Several large randomised controlled trials have shown benefits of different educational techniques in reducing pain and increasing coping skills. Function can reliably be improved by quadriceps strengthening exercises and there is enough evidence to show the positive effects of weight reduction on the progression of the disease process. In conclusion, evidence based guidelines in the conservative management of knee OA exist. Orthopaedic Surgeons should have knowledge of the various approaches and be aware of the fact that certain clinical propositions are supported by substantial research based evidence, while others are not

Between 1992 and 2000, 57 patients with 57 isolated fractures of the medial malleolus were treated conservatively by immobilisation in a cast. The results were assessed by examination, radiography and completion of the short form-36 questionnaire and American Orthopaedic Foot and Ankle Society ankle-hindfoot score. Of the 57 fractures 55 healed without further treatment. The mean combined dorsi- and plantar flexion was 52.3° (25° to 82°) and the mean short form-36 and American Orthopaedic Foot and Ankle Society scores 48.1 (28 to 60) and 89.8 (69 to 100), respectively. At review there was no evidence of medial instability, dermatological complications, malalignment of the mortise or of post-traumatic arthritis. Isolated fractures of the medial malleolus can obtain high rates of union and good functional results with conservative treatment. Operation should be reserved for bi- or trimalleolar fractures, open fractures, injuries which compromise the skin or those involving the plafond or for patients who develop painful nonunion

Introduction. Meniscal tears in middle-aged patients are common. There is a lack of consensus regarding the optimum management of these injuries. Although arthroscopic partial meniscectomy (APM) is a frequently performed surgical option, literature has failed to prove its effectiveness over conservative approaches. Materials and Methods. We retrospectively reviewed 102 middle-aged (age > 40 years) patients who had been treated for meniscal tears between January 2010 and December 2012. We followed these patients up telephonically to assess knee outcome satisfaction rates, any early (6 weeks) improvements in pain and knee function and their pre-morbid and post-treatment activity levels (Tegner Activity Scale). Results. There were 65 male and 37 female patients with an average age of 58 years (range 40–79). After their first consultation 72 patients were treated conservatively and 30 patients were treated with an APM. There were no reported complications following surgery. We managed to contact 87 patients who were followed up at an average of 17.5 months (range 5–34 months). Overall, 72.4% of patients managed were satisfied with their knee outcomes. APM had a 78.9% satisfaction rate and 67.3% of patients treated conservatively were satisfied. There were no significant differences in early or long term pain or knee function improvements between APM or conservative modalities. 89.7% of patients returned to the same or better activity levels after treatment. There was a 1.5 times greater risk of worse activity level following APM. There was a 79.3% satisfaction rate in patients who remained at the same activity level (p=0.00). Analysis showed 21 of the 72 conservatively treated patients failed this approach. APM was performed on 18 of them resulting in a 75% satisfaction rate for this group. Conclusion. APM and conservative management produce equivalently good results for meniscal tears in middle-aged patients. Delayed surgery does not negatively influence the outcome of these patients. NO DISCLOSURES

Introduction: We prospectively followed all hip fracture patients admitted between 2004–2006, identified cases where the intention was to treat conservatively and compared their functional outcome and mortality with a similar cohort treated surgically over the same period. Methods: We recorded length of hospital stay, place of discharge, pre and post-fracture mobility and residence, 30 day and 1 yr mortality, re-admission and delayed surgery. The group treated surgically was recruited and matched for age, gender, pre and post fracture mobility, mental confusion and independence with the conservatively treated group. Results: 25 patients were treated conservatively. 22 patients treated surgically over the same period were recruited. The mean hospital stay was 13 days in both groups. There were 4 extracapsular (3 displaced) and 21 intracapsular fractures (5 displaced) in the conservative arm and 11 extracapsular and 9 intracapsular fractures in the surgically treated arm. 4 patients from the conservative treatment group underwent late surgery 20 days – 2 months after the index event. Surgically treated group had 11 dynamic screw fixation, 1 cannulated screw, 1 total hip replacement and 7 hemiarthroplasty. 9/14 of the conservatively treated patients were mobile independently or with aid after treatment compared to 11/16 patients after surgery. 7/16 patients treated conservatively were living independently in their own residence, compared to 10/14 patients in the operatively treated patients. 1 month and 1 year mortality in conservatively treated group was 4/21 and 7/21 respectively compared to 1/20 and 5/20 in the operative fixation group. There was no statistically significant difference in mobility, residence or mortality between the two groups (Fisher exact test, p > 0.05). Discussion: Conservative management after hip fracture in medically unfit patients does not result in statistically significant difference in functional outcome or mortality compared to patients treated surgically

Background. Patients presenting with an acute tendoachilles (TA) rupture are managed in a dedicated clinic led by a Foot & Ankle Consultant and specialist physiotherapist. The diagnosis is made clinically and no ultrasound scan is performed. All management, rehabilitation and follow-up is undertaken within this clinic by the specialist physiotherapist, with Consultant support as required. Patients are offered a choice of conservative or surgical management (percutaneous TA repair). Both groups undergo a standardised functional rehabilitation regimen. Methods. All patients treated through our dedicated clinic between May 2010 and April 2016 were identified. Patient outcomes were reported using the validated Achilles Tendon Repair Score (ATRS). ATRS scores were collected at 3, 6 and 12 months post-injury. Re-rupture and complication rates were also documented. Results. 167 patients were identified. 79 patients underwent a percutaneous repair and 88 patients opted for conservative management. Mean age of patients undergoing percutaneous repair was 46 years (21–77 years) and 52 years (19–88 years) in the conservatively managed group. Male to female ratios were equal between both groups. Mean ATRS scores at 3, 6 and 12 months were 41.6, 69.5 and 85.3 respectively for the percutaneous repairs and 45.4, 69.0 and 77.1 respectively for the conservatively managed group. The re-rupture rate was 4.2% (3 patients) in the conservative group and 0% in our surgical group. In the surgical group, 1 patient developed a PE and 1 had a wound complication. Discussion. Our dedicated clinic for managing TA ruptures has proved popular with patients, with a patient satisfaction score of 98.7%. By standardising our rehabilitation regimen we believe our outcomes have improved. Our percutaneous repair group has an improved ATRS score compared to our conservative group at 12 months post injury. We believe that any fit active individual should be offered a percutaneous repair irrespective of age

The aim of management of an adult distal humeral fracture is to restore mobility, stability and pain-free elbow function. Good results are usually achieved in the majority of fractures treated with ORIF, but the management of comminuted fractures in elderly, frail patients with osteoporotic bone remains controversial. The literature focuses on elbow replacement if stable internal fixation cannot be achieved, with “bag-of-bones” management now rarely discussed eg. key-note paper - 10 successful cases reported by Brown RF & Morgan RG in 1971 (JBJS 53-B(3):425-428). We present the experience in two units in which conservative management has been actively adopted in selected cases by consultants with a subspecialty interest in the elbow. All patients over the age of 60 with distal humeral fractures (2007 – 2009) who had been treated conservatively were reviewed clinically and radiologically. Duration of follow-up and outcome, including the Oxford and quick DASH scores, were recorded, with the fractures classified using the AO system. There were 25 patients, 19 female and 6 male. 19/25 patients have been successfully treated conservatively with a mean Range Of Movement: Extension/Flexion: 45/125, Pronation/Supination 74/70. Only 5 underwent subsequent total elbow replacement and one delayed ORIF. There is a significant complication rate following surgical treatment with ORIF or elbow replacement in elderly, frail patients, including infection, painful non-union and/or stiffness. We believe that there is a role for initial conservative treatment in selected patients with low, displaced, comminuted humeral fractures in osteoporotic bone. Initial early mobilisation as pain allows can give good functional results without the risks of operation. It does not preclude future surgery if conservative treatment fails, but this is not required in the majority of cases

There are many reasons that the surgically inclined orthopaedic surgeon should be responsible for the medical management of osteoarthritis of the knee. These include: 1) The nonoperative treatment of OA is often highly effective for all stages of the disease; 2) A nonoperative treatment program is the best preparation for a successful surgical outcome; and 3) Patients appreciate a surgeon's interest in their overall care and are likely to return if surgery is needed; 4) Medicare and many insurance companies are refusing to pay for a TJA until many months of conservative management has been administered. There are many potential causes of pain in an arthritic knee. These include intra-articular (e.g. degenerative meniscal tears, loose bodies, synovitis) and extra-articular (tendonitis, e.g. ilio-tibial band syndrome, bursitis, muscle overload syndromes and referred pain) sites. The potential sources of pain in an arthritic knee produce a wide range of symptoms that are not necessarily correlated with objective measurements (e.g. x-rays, MRI). Moreover, the natural history of an arthritic knee is unpredictable and variable. The treatment of the young, arthritic knee patient of all stages requires a systematic and consistent non-surgical approach. This approach includes the use of: 1) analgesics/anti-inflammatory agents; 2) activity modification; 3) alternative therapies; 4) exercise; 5) injections/lavage. The response to each form of non-surgical treatment is unpredictable at each stage (Kellgren 1–4) of OA. The placebo effect of each from of treatment, including the physician-patient interaction, is 50–60% in patients with mild-moderate OA. The components of a nonoperative treatment program include: 1) Education-emphasising the importance of the patient taking charge of his/her care; 2) Appropriate activity/life style modifications-emphasising the importance of remaining active while avoiding activities that aggravate symptoms (e.g. running to biking); 3) medications-oral, topical, intra-articular; 4) Physical therapy. There are extensive data to support each of these interventions. The AAOS has issued guidelines highlighted the literature based effectiveness of conservative interventions

Purpose of the study: Advances in chemotherapy protocols over the last 20 years have considerably improved the prognosis and functional outcome in patients with osteogenic sarcoma. We report here the results of a cooperative study conducted under the auspices of the French Society of Pediatric Oncology (SFOP). Twenty-nine oncology centers participated in this retrospective national multicentric study. Materials and methods: The study included 15 .3 patients with osteogenic sarcoma of the limb who were treated by the OS87 protocol with conservative surgery between 1987 and 1994. The OS87 protocol consisted in conservative or nonconservative surgery combined with pre- and postoperative chemotherapy. The following inclusion criteria were used: age under 20 years, tumor localization in a limb (pelvis and spine excluded), no metastasis at diagnosis, biopsy proven osteogenic sarcoma. Results: Mean age at diagnosis was 13 years. The knee localization predominated (80 p. 100). 82.5 p. 100 of the patients had grade IIB disease (Enneking classification). For the 187 patients included in the protocol surgery was nonconservative in 20 p. 100 of the cases and conservative in 80 p. 100. The choice of the surgical technique (arthroplasty, allograft, autograft, resection without reconstruction) depended on the patient’s age and school situation. Data analyzed here concerned only those patients who had conservative treatment. Mean follow-up was 64 months. The actuarial survival curve plateaued at 71 p. 100 at more than 6 years. Early and late complications were numerous and variable (mechanical, infectious, local recurrence). Secondary amputation was required in 10 p. 100 of the patients. The overall functional outcome of the preserved limbs was nevertheless good with rapid restoration of self-sufficiency despite major surgery and a high number of reoperations (about 65 p. 100 of cases). Discussion: In light of the frequency and the seriousness of the complications, these results are modest. Patients and family should be advised of the risk, particularly the risk of secondary amputation which may be required early due to contaminated excision or at mid term due to major non-cancerological complications. As survival has been improved, functional capacity must be preserved for several years. This orients surgery towards more “biological” reconstruction which can provide greater longevity than arthroplasty

Purpose: The purpose of this study was to evaluate total hip arthroplasty (THA) in the treatment of posttraumatic arthritis following acetabular fracture and to compare the long-term outcome of THA after previous open reduction and internal fixation (ORIF) or conservative treatment of the acetabular fracture. Method: Thirty-four patients (thirty-six hips) underwent total hip arthroplasty for arthritis resulting from acetabular fractures. There were twenty-six males (27 hips) and eight females (9 hips). The mean age at the time of hip arthroplasty was 49 years (range, 25–78 years). The mean follow-up was eight years and nine months (range, 4–17 years). The mean interval from fracture to arthroplasty was 7.5 years (range, 5 months-29 years). Two patients died of unrelated causes and two patients were lost to follow up. Thirty patients (32 hips) were available for latest follow up. Twenty-one hips had been previously treated by open reduction internal fixation and 11 hips had conservative treatment. Results: Sixteen patients achieved and maintained a good to excellent result over the course of the follow-up. There was no difference in improvement of mean Harris Hip Score between both groups (p> 0.05). Ten out of 32 hips required revision; 9 acetabular components were revised because of aseptic loosening (3), osteolysis/excessive wear (4), instability (1) and infection (1) with a total revision rate of 28%. Eight patients needed acetabular revision alone, one femoral revision alone and one revision of both components. There was no significant difference in bone grafting, heterotopic bone formation, revision rate, operative time and blood loss between the two groups (p> 0.05). Conclusions: Those patients initially treated conservatively had similar long term results compared to those treated primarily by open reduction internal fixation. At long term follow-up the main problem identified was osteolysis and acetabular wear

Introduction In this institution a structured program of conservative management of Achilles tendon rupture has been developed combining a conservative and orthotic treatment regime with a view to adding the advantages of a removable orthosis to traditional non-operative therapy. This study compares the results of this protocol to published surgical results. This is the largest detailed study of conservative management of Achilles tendon rupture in the literature to date. Methods We assessed 140 subjects who had a complete rupture of their Achilles tendon treated with our combined conservative and orthotic regime between 1992 and 1998. Subjective assessments of symptoms and objective measurements of ankle range of motion, calf circumference and isokinetic measurements of ankle plantar flexion and dorsi flexion were recorded. Patients also completed a functional heel-rise test. Our results have been compared to published series. Results Our overall results showed 56% had excellent, 30% good, 12% fair and two percent poor results. The overall complication rate was four percent, with three tendon reruptures. When compared with published results for operative repair, our combined conservative and orthotic treatment produces better results overall. Patients are subjectively happier, they have better strength results and have fewer complications. In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source

Introduction: We reviewed the complications and recovery of patients treated for Achilles tendon rupture by percutaneous repair, open repair, and non-operative management in a tertiary referral centre between 2001 and 2003. Materials and Methods: We identified patients who underwent Achilles tendon rupture repair by percutaneous or open methods from the logbooks of Consultants and the operating theatre register. We used plaster room records were also used to identify patients who received non-operative treatment. We collated demographic and management details, and compared them with published rates relating to average age range, demographic, and management details. Results: In the 20 patients who underwent open repair, one (4.8%) patient sustained a re-rupture, four (19%) sustained minor complications, and one (4.8%) had a major complication. In the 31 patients who underwent percutaneous repair, one (3.2%) patient sustained a major complication, six (19.4%) patients experienced minor wound complications, and there were no re-ruptures. In the 12 patients who underwent conservative management, re-ruptures occurred in one patient (8.3%), minor complications occurred in five patients (41.7%), and there were no major complications. The median recovery time in the open, percutaneous and conservative groups was 25 weeks, 26 weeks and 18.5 weeks respectively. Discussion and Conclusion: In our setting, percutaneous repair is the most successful management method, with no re-ruptures and very few complications. Although conservative management produced the highest rate of complications, each patient will have different needs due to their age, occupation or level of sporting activity. Ultimately, the decision of the management regime used probably lies with the patient

To clarify the short-term results of conservative treatment for symptomatic full-thickness tears of the rotator cuff. Between September 1996 and August 1999, 107 shoulders of 105 patients were diagnosed as full-thickness tears of the rotator cuff by MRI or arthrography at our institute. All patients were treated conservatively and only 3 shoulders underwent surgery because of persistent pain after 6 months of conservative treatment. Among 104 shoulders treated conservatively for more than 12 months, 102 shoulders of 100 patients were followed up with an average follow-up period of 33 months. Two patients were excluded: one had died and the other had been lost at the time of follow up. Among 102 shoulders, 56 shoulders of 56 patients were assessed by direct examination, and 44 shoulders of 46 patients were interviewed by telephone. There were 54 males and 46 females with an average of 64 years (44–80). The Shoulder Functional Evaluation by the Japanese Orthopaedic Association (JOA score) was used for assessment (full score = 75 points). The overall JOA score improved significantly from 41.3 points (initial) to 63.5 points (follow-up) (p< .01). Satisfactory results (> - 60 points) were obtained in 71%. The pain score (full score = 30 points) improved from 8.3 points (initial) to 24.7 points (follow-up) (p< .01). At follow-up, 49% had no pain and 88% did not need any medication. The range of motion, abduction strength, and activities of daily living improved significantly (p< .01). Angle of external rotation at initial examination was positively correlated with the JOA score at follow-up (r=0.373, p> .01). Short-term outcome of conservative treatment for symptomatic full-thickness tears of the rotator cuff was satisfactory in 71% of the patients

Femoral neck fractures are the second cause of hospitalization in elderly patients. Nowadays it is still not clear whether surgical treatment may provide better clinical outcome than conservative treatment in patients affected by mental disorders, such as senile dementia. The aim of this study was to retrospectively assess mortality and clinical and functional outcome after hemi arthroplasty operation following intracapsular neck fractures in patients with senile dementia. Between 2008 and 2014, 819 patients were treated at our Orthopaedic Institute for neck fracture of the femur (mean age: 83.8 years old). Eighty-four of these showed clear signs of cognitive impairment at time of admission in the Emergency Department. Mental state of patients was assessed in all cases, as routine, at the Emergency Room with the Short Portable Mental Status Questionnaire (Sh-MMT) and the Mini Mental State Examination (MMSE). Patients were divided in two groups depending whether they were surgically treated with hemiarthroplasty (Group B, 46 patients; 35 females, 11 males; mean age: 88.5 y.o.) or conservatively treated (Group C, 38 patients; 28 females, 10 males; mean age: 79.5 y.o.). These two groups were compared with a matched case-control group of patients surgically treated with no mental disorders (Group A, 40 patients; 34 females, 6 males; mean age: 81.5 y.o.). Incidence of mortality, systemic or local complications and functional clinical outcomes were evaluated with the ADL score and the Barthel index. Mortality rate was 35% (14 patients) for Group A, 50% (21 patients) for Group B and 95% (22 patients) for Group C. Paired t-test, with significance rate set at 0.05, showed significant higher mortality rate in Group A compared to both Group B (p:0.02) and Group C (p:0.001), and also between Group B and Group C (p:0.01). Three orthopaedic complications were found in Group B (two cases of infection and one dislocation of the prosthesis) while none in Group A (p<0.001). There have been 14 overall general complication in Group A (33%), 16 in group B (38%) and 15 in Group C (65%), with significant higher rate in Group B vs. Group A (p:0.02) and in group C vs. Group B (p: 0.001). Activity daily living scale and Barthel Index results showed higher results in Group B than Group C both in terms of recovery of walking ability and daily living (hairdressing, wearing clothes, eating). For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Between 1985 and 1993, 146 patients (162 hips) had total hip replacement (THR) using a conservative uncemented femoral component. The mean age of the patients was 50.8 years and the mean follow-up was 6.2 years (2 to 13). One patient was lost to follow-up, one died within two years of surgery and one had a revision procedure after a fracture sustained in a road-traffic accident. For the remaining 159, Kaplan-Meier survival analysis was calculated for the incidence of revision because of mechanical loosening or osteolysis. Survival without mechanical loosening at both five and ten years was 98.2%. Survival without osteolysis was 99% at five and 91% at ten years. The Harris hip score improved from a mean of 66.3 before to 90.4 at follow-up. Of particular note is the lack of thigh pain in this group. Radiological analysis showed that 139 stems (88%) had no measurable subsidence, 8 (5%) had less than 2 mm and 12 (7%) had more than 2 mm. Two of the eight and one of the 12 were revised for mechanical loosening. Nine hips were revised for late loosening associated with osteolysis. No reaming of the femoral canal was associated with statistically significant less blood loss compared with a comparable control group of uncemented implants (p < 0.0001). Our study suggests that using a conservative femoral implant does not protect against wear debris but the reliable mechanical stability (98.2%) makes this an attractive design of implant particularly for young patients

Introduction. Although the majority of adult distal humeral fractures are successfully treated with ORIF, the management in frail patients, often elderly with multiple co-morbidities and osteoporotic bone, remains controversial. Elbow replacement is frequently recommended if stable internal fixation cannot be achieved, especially in low, displaced, comminuted fractures. The “bag-of-bones” method ie early movement with fragments accepted in their displaced position, is rarely considered as there has been little in the literature since 10 successful cases were reported by Brown & Morgan in 1971 (JBJS 53-B(3):425–428). We present the experience of three units in which conservative management has been actively adopted in selected cases. Methods. 44 distal humeral fractures were initially treated conservatively - 2004–2010. Mean age 73.9 yrs (40–91) and 34 F: 10 M. Clinical and radiological review at a mean follow-up of 2 years (1–6). Results. There were 18 AO Type A, 7 B and 19 C fractures. The range of elbow movement was extension/flexion 38/124, and pronation/supination 75/76 at their last follow-up. Using the Oxford elbow score (0 = worst/4 best result), the mean pain score was 2.44 (range 1–4), 2.26 (0–4) for function, and 2.04 (0–4) for psycho-social, although several patients had early dementia. Only 5 subsequently underwent replacement out of 44 patients whose residual symptoms have not been sufficient to require surgery. Discussion. We believe that there is a role for initial conservative treatment in selected higher-risk patients, as initial early mobilisation within the limits of discomfort can give good functional results. There is a significant complication rate after fixation or replacement in elderly, frail patients, which includes infection, stiffness and loosening. Unnecessary operations can be avoided in the majority of cases, with replacement of a virgin joint at a later date only if required

We report a prospective trial of 66 patients with intraarticular fractures of the calcaneum. All fractures were assessed by CT. Patients with displaced fractures were randomised to receive either conservative (n = 31) or operative treatment (n = 25). Undisplaced fractures (n = 10) were treated conservatively. Operation involved open reduction of the posterior subtalar joint, and fixation with Kirschner wires. All 66 patients were reviewed at a minimum of one year (mean 23 months). After conservative treatment the undisplaced fractures had slightly better results than the displaced fractures. There was no significant difference in outcome between the operatively and the conservatively treated displaced fractures. We have also documented prospectively the natural history of the injury, which is of use in assessing prognosis for both clinical and medicolegal purposes

This is the largest detailed study of conservative management of Achilles tendon rupture in the literature to date. We assessed 140 subjects who had a complete rupture of their Achilles tendon treated with our combined conservative and orthotic regime between 1992 and 1998. Subjects were assessed subjectively and objectively, including isokinetic measurements of ankle plantarflexion and dorsiflexion. Overall 56% had excellent, 30% good, 12% fair and 2% poor results. The complication rate was 4%, with only 3 tendon reruptures. When compared with published results for operative repair, our combined conservative and orthotic treatment produces better results overall. Patients are subjectively happier, they have better strength results and have fewer complications

The purpose of this study was to evaluate total hip arthroplasty (THA) in the treatment of post-traumatic arthritis following acetabular fracture and to compare the long-term outcome of THA after previous open reduction and internal fixation (ORIF) or conservative treatment of the acetabular fracture. Thirty-four patients (thirty-six hips) underwent total hip arthroplasty for arthritis resulting from acetabular fractures. There were twenty-six males (27 hips) and eight females (9 hips). The mean age at the time of hip arthroplasty was 49 years (range, 25-78 years). The mean follow-up was eight years and nine months (range, 4-17 years). The mean interval from fracture to arthroplasty was 7.5 years (range, 5 months-29 years). Two patients died of unrelated causes and two patients were lost to follow-up. Thirty patients (32 hips) were available for latest follow-up. Twenty-one hips had been previously treated by open reduction internal fixation and 11 hips had conservative treatment. Sixteen patients achieved and maintained a good to excellent result over the course of the follow-up. There was no difference in improvement of mean Harris Hip Score between both groups (p>0.05). Ten out of 32 hips required revision; 9 acetabular components were revised because of aseptic loosening (3), osteolysis/excessive wear (4), instability (1) and infection (1) with a total revision rate of 28%. Eight patients needed acetabular revision alone, one femoral revision alone and one revision of both components. There was no significant difference in bone grafting, heterotopic bone formation, revision rate, operative time and blood loss between the two groups (p> 0.05). Those patients initially treated conservatively had similar long term results compared to those treated primarily by open reduction internal fixation. At long term follow-up the main problem identified was osteolysis and acetabular wear

Introduction: The treatment of the recently ruptured Achilles tendon is still controversial. Surgical procedures are commonly considered to restore excellent functional capacity and suffer low re-rupture rates, but are potentially associated with significant complications like wound infection and paraesthesia. Recent studies report very good results with a conservative treatment in rigid casts. Our aim was to evaluate a new method of functional and conservative treatment using immobilisation in an articulated cast. Patients and Methods: Between March 1998 and August 2005, 12 women and 45 men with an average age of 45 (24–73), underwent a functional and conservative treatment for a recently ruptured Achilles tendon. After an immobilisation with a cast in equinus for 10 days, the patients were authorised to walk with full weight-bearing, protected by a commercial orthosis (VACO®ped, OPED). The equinus angle was set at 30° plantar flexion until the end of week 3, and at 15° until the end of week 4. At the 5th week the system was unlocked to allow ankle mobilisation of 30-15-0°, and at 30-0-0° at the seventh week. The orthosis was removed after 8 weeks. All patients had follow-up examinations up to 12 months after the trauma. The first 30 patients underwent a clinical examination and muscular testing with a Cybex isokinetic dynamometer at 6 and 12 months. In June 2006 all 57 patients were contacted and received a questionnaire. Their subjective opinions of the outcome, any change in their sport activities and eventual late complications were investigated. We evaluated the questionnaire and medical records using a scoring system based on the Leppilahti Ankle Score. Results: After one year there was not any difference in the motion of the ankle in comparison with the healthy side. There was no substantial calf amyotrophy and we found very little difference in muscular capacity. The average overall satisfaction with the outcome was 8.1 out of 10. We observed 5 complete re-ruptures (9%), 2 partial re-ruptures and 1 deep venous thrombosis complicated by pulmonary embolism. We observed few minor skin complications. Conclusions: The present treatment resulted in good to excellent functional results in most of the cases. It requires an active participation of the patient and a systematic medical follow-up during the first 6 months. The complication rate is acceptable. We think that early ankle mobilisation in the dynamic cast promotes better functional results than a rigid immobilisation technique. There is a place for conservative functional treatment in the acute rupture of the Achilles tendon. But prospective comparison with modern surgical techniques, like minimal invasive suture, is still required, especially in patients with high functional demand

Aim. We aimed to assess the efficacy of conservative management of proximal phalanx fractures in a plaster slab. Methods. 23 consecutive patients with proximal phalanx fractures were included in this prospective study. The fractures were reduced and the position was held with a dorsal slab for three weeks. They were followed up an average of 7 weeks (range 2 to 45) after the injury. Radiographic confirmation of adequate reduction was carried out each week until union. After removal of the plaster, range of motion of the finger and radiological evidence of union, non-union or malunion was documented. Results. In united fractures, an average angulation of 4° (apex volar) was measured (range 0 to 45°). In one case (45°) this was not acceptable. All other cases measured less than 15° of angulation. On the AP radiograph the angulation was on average 2° (range 0 to 8°). On average 1.3 mm of shortening (range 0 to 5mm) were measured. In one case delayed union with rotational deformity of 20° was evident. After removal of the slab mild stiffness was noted in one case at the metacarpophalangeal joint and in two cases at the proximal interphalangeal joint. Conclusion. Most proximal phalanx fractures can be managed conservatively with acceptable results. NO DISCLOSURES

We made a retrospective study of 149 children and adolescents with moderate spondylolisthesis (slip less than or equal to 30%), 77 treated by fusion and 72 conservatively at an average follow-up of 13.3 years. Both groups were fully comparable with regard to age at diagnosis, sex distribution (46% girls), and mean slip. The patients who were treated operatively had more pain before treatment and showed more initial progression of the slip. They had better clinical results and less pain at latest review, but the total progression of the slip over the whole follow-up showed no statistical differences between the two groups. Patients with a pseudarthrosis after attempted fusion had had a longer period of postoperative pain, but at the latest review had no more pain than those with sound fusion. None of those treated conservatively came to fusion later and the long-term results in 18 patients who had refused the advised operation were no worse than those for other conservatively treated patients. Our results suggest that a moderate grade of spondylolisthesis in adolescents usually has a benign course. It seems that spontaneous segmental stabilisation occurs as a result of degeneration of the disc at the level of the slip

Treated conservatively, hyperextension injuries of the cervical spine have a poor outcome, but surgical treatment does not yet provide a realistic alternative. This study was prompted by the lack of classifications of cervical spondylosis and outcome studies of hyperextension in the literature, and the absence of a user-friendly neurological score. The retrospective study included 60 patients admitted over the last 12 years with hyperextension injuries and varying degrees of neurological deficit. The mean age of patients was 52 years and most had radiological evidence of cervical spondylosis. None had any neurological deficit before the accident. Injuries were sustained in falls in 56%, in motor vehicle accidents in 34%, in assaults in 8% and in sports injuries in 2%. The neurological deficits varied: 11% had complete lesions, 33% central cord syndrome, 18% motor complete-sensory incomplete, 33% motor incomplete-sensory incomplete. The nervous system was normal in 2%. The posterior columns were often involved, with loss of pro-prioception. In the majority of cases conservative treatment consisted of six weeks of light traction in gentle flexion, followed by mobilisation in an ABCO brace for six weeks. The results showed that the mean Asia score gain for the group treated conservatively was 23, for the surgically stabilised group 3 and the surgically- decompressed group 55. There was a 16% mortality rate. The mean time for rehabilitation was 5.5 months. Both the final outcome and the time to rehabilitation were extremely variable. We present a classification of cervical spondylosis and ways of measuring congenital and acquired spinal cord narrowing. We combine the Asia and Frankel scoring systems to give a user-friendly guide

BACKGROUND. As life expectancy in the population rises, osteoporotic fractures are seen most frequently in the vertebral column. Percutaneous kyphoplasty is increasingly used for pain reduction and stabilization in these patients, but the efficacy, cost-effectiveness, and safety of the procedure remain uncertain. OBJECTIVE. To clarify whether kyphoplasty has additional value compared with optimum pain treatment in patients with acute vertebral fractures. MATERIALS & METHODS. From January 2004 to June 2009, 122 patients (31 males and 91 females), from 56 to 85 years old (mean age 68.5) were treated for 165 osteoporotic vertebral fractures of the thoracic or lumbar spine (minimum 15% height loss; level of fracture at Th5 or lower; bone oedema on MRI), with back pain for 6 weeks or less, and a visual analogue scale (VAS) score of 5 or more. Twelve patients (15 fractures) were lost at follow-up period and excluded. Patients were randomly allocated to percutaneous kyphoplasty (75 patients) or conservative treatment by computer-generated randomization codes. All fractures were analyzed for improvement in sagittal alignment (Cobb angle, kyphotic angle, sagittal index, vertebral height); and pain relief at 1, 6, 12, 24 months, as measured by VAS score. RESULTS. Percutaneous kyphoplasty resulted in direct and greater pain relief than did conservative treatment; difference in mean VAS score between baseline and 1 month was −6,5 after kyphoplasty and −2.4 after conservative treatment, and between baseline and 1 year was −7.2 after kyphoplasty and −3.8 after conservative treatment. No serious complications or adverse events were reported. Apart from the pain, the patient's ability to ambulate independently and without difficulty, and the need for medications improved significantly (P < 0.001) after kyphoplasty. Vertebral height significantly increased at all postoperative intervals, with 10% height increases in 88% of fractures, in kyphoplasty group at 2 years. There were no severe kyphoplasty-related complications, such as neurological defects, cement leakage or narrowing of the spinal canal whereas additional fractures occurred at the adjacent vertebrae at a rate of 10%. 35% of patients treated conservatively, had limitations in everyday activities the first 6 months, whereas additional fractures occurred at the adjacent vertebrae at a rate of 14%. CONCLUSION. In patients with acute osteoporotic vertebral compression fractures and persistent pain, balloon kyphoplasty is effective and safe. Pain relief after kyphoplasty is immediate, is sustained for at least 2 years, and is significantly greater than that achieved with conservative treatment, at an acceptable cost

Case Report: Metastatic deposits in the proximal femur commonly result in pathological fracture. Conventionally these fractures are treated surgically, by internal fixation or arthroplasty. The emphasis in treating these fractures is on restoring stability to the proximal femur and relieving pain. We present two cases in which pathological fractures of the proximal femur secondary to metastatic renal carcinoma were treated conservatively with excellent functional outcomes. In both cases, the medical condition of the patient precluded surgery. A 68 year old male with a subcapital fracture of the proximal femur was treated with bedrest and mobilisation. At 6 months he was able to mobilise with crutches, swim, and had returned to almost all normal activities despite non-union of the fracture. A 63 year old male had a pathological fracture of the proximal femur treated by DCS fixation. The fracture failed to unite and the plate fractured. Despite this the patient was able to walk with crutches, pain free. Discussion: After a pathological fracture of the proximal femur conservative management can lead to satisfactory analgesia, function and therefore quality of life

There is no clear consensus regarding the indications for surgical treatment of middle third clavicle fractures. An initial shortening of 2 cm or more of the clavicle was associated with poor clinical outcomes and higher rate of non-union. The number needed to treat (NNT) clavicle fractures in order to prevent non-union ranges in the recent literature from 4.5 to 9.2. A direct relationship between shortening of the clavicle and a poor clinical outcome has not yet been demonstrated. Prospective cohort study performed in a Level one trauma centre including 148 clavicle fractures treated conservatively. Eighty-five patients met the inclusion criteria (healed fracture in the middle third, no other upper limb lesions) and 63 were enrolled. A single assessment was realised at a minimum one year follow-up by an independent examiner and consisted in Constant and DASH scores, range of motion, strength in abduction (Isobex) and a specific radiographic evaluation using a calibrated AP radiographs of both clavicles. Two groups were constituted and analysed according to a radiologic shortening > 2 cm (patients and assessor blinded). Sub-analyses were performed to find any relevant clinical threshold. The rate of shortening > 2cm in this cohort is 16.1% (10 patients). No clinical differences between the two groups for Constant scores (shortened > 2 cm = 96.0 ± 6.0 vs 95.2 ± 6.6, p=0,73) and DASH scores (8.4 ± 11.9 vs 5.4 ± 8.1, p=0,32). A slight loss in flexion was observed with a shortening > 2cm (175 deg ± 8.5 vs 179.3 ± 3.4, p=0,007). No clinical threshold (in absolute or relative length) was associated with lower functional scores. No relationship between clinical results and patient characteristics. Interestingly, cosmesis was not an issue for patients. This study could not demonstrate any clinical impact of the shortening of the clavicle in patients treated conservatively for a fracture in the middle third. Functional scores are excellent and the slight difference in flexion is not clinically significant. We were not able to found patients unsatisfied with their treatment. The poor functional outcomes described in previous studies are mainly related to non-unions. Just after the trauma, protraction of the scapula and single AP views centered on the clavicle can overestimate the real shortening. An initial shortening of the clavicle > 2 cm is not a surgical indication for fractures in the middle third; patient selection for surgery should focus on risk factors for non-unions

Introduction: Conservative hip replacements are advantageous because resection of bone in the proximal femur is minimised. This study investigated a new design of conservative hip in the goat model where the femoral head was resected and two hydroxyapatite coated ‘pegs’ were introduced into the femoral neck. The hypothesis was that the ‘pegs’ would provide a direct method of transmitting forces within the femoral neck thus resulting in less adverse bone remodelling and reduced loosening. Bone stock is also preserved should subsequent revision be required. Methods: Eight unilateral implants were inserted into the right femur of adult female goats for 1 year. Retrieved specimens were analysed radiographically and histologically. Image analysis was used to quantify bone attachment and total bone area adjacent to the implant. Tetracycline bone markers quantified bone turnover. Operated hips were compared with non-operated hips. The students t-test was used for comparative statistical analysis where p< 0.05 were classified as significant. Results: Radiographic analysis demonstrated bone loss beneath the cup with increased bone density at the distal end of the pins (fig.1). Light microscopy revealed areas of new and mature bone adjacent to the implant. Osseointegration to the HA coating was observed. Bone markers established significantly decreased bone formation rates (p< 0.05) in bone adjacent to the implant in the operated versus control hips. Image analysis results demonstrated an average bone attachment of 30.94% to the implant surface (fig 2). Greatest bone attachment occurred at the end of the pins (78.99%) contributing 22% of overall attachment to the implant. Least attachment occurred beneath the prosthetic cup (13.82%) and in the medial aspect adjacent to the central pin. Greater total bone area was measured in control hips and no significant correlation between bone attachment to the ‘pegs’ and bone area beneath the prosthetic cup was identified. Discussion: From this study we have concluded that despite the resorption of bone beneath the prosthetic cup, the conservatve hip design investigated remained well fixed in the femur during the 1 year in vivo period. It appears that an implant design that resurfaces the femoral head with two pins used to transmit forces into the femoral neck is a useful approach in conservative hip design

This is a retrospective study of six children with ununited scaphoid fractures treated conservatively. Their mean age was 12.8 years (9.7 to 16.3). Five had no early treatment. Radiological signs of nonunion were found at a mean of 4.6 months (3 to 7) after injury. Treatment consisted of cast immobilisation until clinical and radiological union. The mean clinical and radiological follow-up was for 67 months (17 to 90). We assessed the symptoms, the range of movement of the wrist and the grip strength to calculate the Modified Mayo Wrist score. The fracture united in all patients after a mean period of immobilisation of 5.3 months (3 to 7). Five patients were pain free; one had mild pain. All returned to regular activities, and had a range of movement and grip strength within 25% of normal, resulting in an excellent Modified Mayo Wrist score. Prolonged treatment with cast immobilisation resulted in union of the fracture and an excellent Modified Wrist Score in all patients

Autologous micro-fragmented adipose tissue (MFAT) for the treatment of symptomatic knee osteoarthritis (OA) is gaining interest although there is still a lack of supportive data on safety and clinical efficacy. This study primarily aimed to identify patient- and pathology-related parameters to tighten patient selection criteria for future clinical MFAT application. Secondly, the overall (1) therapeutic response rate (TRR), (2) short-term clinical effect, (3) effect durability and (4) therapeutic safety was investigated at a minimal follow-up of 1 year.

Sixty-four subjects (91 knees) with symptomatic knee OA (mild-severe on MRI) were enrolled in a prospective single-centre case series. Ethical approval was obtained from the local and academic ethical committee (#B300201733775). After liposuction, the adipose tissue was mechanically processed in a Lipogem® device which eventually produced 6–9cc MFAT. Subjects were clinically assessed by means of the KOOS, NRS, UCLA and EQ-5D at baseline and 1, 3, 6 and 12 months after injection. Adverse events were meticulously recorded. The TRR was defined according to the OMERACT-OARSI criteria. A baseline MRI was scored following the MOAKS system. Paired sample t-tests, independent t-test and Fischer's exact test were applied on appropriate variables. Multiple regression models were fit separately for patient-and pathology-specific factors. Significance level was set at α=0.05.

The overall TRR was 66% at 3 months and 50% at 12 months after injection. Subgroup analysis revealed that specifically patients with no-mild bone marrow lesions (BML) had a TRR of 88% at 3 months and 75% at 12 months after MFAT injection. Therapy responders at these timepoints improved with 29.3±14.1 points and 30.8±15.3 points on KOOS pain, while non-responders deteriorated mildly. All clinical scores were significantly higher at follow-up compared to baseline (p<0.05). BMI (factor 0.17, p=0.002) and age (factor −0.48, p=0.048) were prognosticators for the TRR% at 1 month and for absolute KOOS pain improvement at 6 months, respectively. Posterior horn lesions (PHL) in the medial meniscus (p<0.001) and bone marrow lesions (p=0.003) were negative prognosticators for the TRR at respectively 6 and 12 months post-injection. An inflammatory reaction (pain, swelling or stiffness) to MFAT was reported in 79% knees and resolved spontaneously within 16.6±13.5 days after administration.

The study showed a durable and satisfying TRR (up to 75% at 1 year in selected patients without BML) and clinical improvement after a single intra-articular injection with autologous MFAT. The availability of an index knee MRI is mandatory to select MFAT patients, preferably with no or mild BML and without PHL of the medial meniscus. High BMI and younger age are associated with better early outcomes. In comparison to other injection therapies such as cortisone, hyaluronic acid and PRP, MFAT appears very attractive with an effect durability of at least 1 year.

Defects of the joint cartilage are of enormous medical and socio-economic impact. Meanwhile is widely acknowledged that untreated cartilage defects lead to an early onset of osteoarthritis. Intrinsic factors for the genesis of osteoarthritis are unknown. It is wellknown however that joint cartilage has only a limited capacity of regeneration. The conservative treatment of early osteoarthritis should focus on the following principles: Limit the pain. Various drugs are available for the symptomatic treatment of osteoarthritis (e.g. NSAIR, cortison, herbal preparations). Intrarticular injections with antiinflammatory agents (e.g. hyaluronan, cortison, IL-1 antagonists) have been proven to reduce pain and dysfunction. Orthetic devices are able to unload joint compartments destroyed by osteoarthritic cartilage lesions. Arthroscopic lavage and debridement eliminate inflammation mediating substances and balance the synovial environment. Maintain the function. Physiotherapy and massage fight the stiffness of the joint and enhance the periarticular circulation. Daily activity should be encouraged and supported e.g. by walking aids and custom-made shoewear. Reduce factors for progression. A successful dietary program can minimize overload of osteoarthritic joints. Surgical procedures to restore and maintain meniscal function, joint stability and physiological loading are beneficial to prevent further cartilage deterioration. Regeneration of cartilaginous surfaces e.g. by marrow stimulation techniques or autologous chondrocyte transplantation will ease joint function and inhibit enzymatic degradation of healthy cartilage. In the last 10 years modern biochemical and cell biological techniques opened new horizons for the treatment of cartilage defects and osteoarthritis Future will teach us the value of cartilage regeneration to treat osteoarthritis. The biologic approach of cell based therapies and the arthroscopic application of resorbable implants widen the indications for the conservative surgical treatment of osteoarthritis

We have reviewed 30 patients who had been treated conservatively for acromioclavicular dislocation between 1979 and 1982 at an average of 12.5 years after the injury. All except one had a good outcome as did five others contacted by telephone. In all patients reviewed the acromioclavicular joint remained subluxed or dislocated. With conservative treatment a good long-term outcome can be expected without restoration of the anatomical configuration of the joint

Purpose of study. The outcomes of conservatively managed minimally displaced isolated greater tuberosity fractures are sparsely reported and the aim of this study was to look at the outcome of these fractures. patients and methods. Twenty-seven patients who had sustained a greater tuberosity fracture were identified. They were all managed by a single surgeon. All patients had a regime of initial immobilisation for 3 weeks followed by physiotherapy and range of motion exercises. They were all x-rayed at 1 week and 3 weeks after injury to monitor for any displacement. Four fractures occurred with an anterior dislocation. In seven patients the fracture was not visible on x-ray but was diagnosed on Ultrasound or MRI. Twenty-three of 27 patients were available for follow-up. For this follow up, the patients were telephonically contacted and the Oxford Shoulder Score (OSS) was completed to assess their outcome. Results. There were 12 males and 11 females in the review. The average age was 44 yrs (6–71 yrs) and the average follow up was 26.2 months (6–43 months). The OSS for the 23 patients ranged from 22–48 (average 44, median 47, mode of 48). Fourteen patients had LASI as part of their management after they started to develop pain and impingement symptoms. The ones with LASI had a slightly lower median OSS (46) compared to those without (48) but the modal scores were the same (48). One patient needed surgery after the initial fracture displaced at 3 weeks while another patient needed an acromioplasty at 10 months for impingement. Three patients developed a frozen shoulder but subsequently settled and had excellent outcome scores. Summary. In this study, 30% (7) of the fractures were not visible on the x-rays but diagnosed on ultrasound or MRI. Nearly half the patients required subacromial steroid injections to improve recovery. In only one patient did the fracture displace and require fixation. Conclusion. Conservative management of minimally displaced greater tuberosity fractures yields good functional results though a high percentage of patients require subacromial steroid injections. Secondary displacement is rare, however close vigilance of fracture is advised with x-rays done at 1 and 3 weeks postoperatively. NO DISCLOSURES

Introduction and Aims: The clavicle has several important functions each of which may be affected after fracture and malunion of the bone. The aim is to establish any association between shortening of the clavicle, following successful conservative management and clinical outcome. Method: 132 patients with history of an acute fracture of the clavicle were reviewed. None of them had previous pathology affecting shoulder function, prior to injury. Men accounted 93 with average age 25.4 years, and women 39 with average age 34.2 years. All underwent conservative management with standard protocols and the fracture was united. The length and relative shortening of the united clavicle were assessed on a standardised posteroanterior chest x-ray. Intra- and Inter-observer reliability of measurements were assessed. Clinical outcome was evaluated with the Constant score. Mean follow-up was 30 months. Results: Clavicular shortening following fracture union was 11.4 mm on average (range 3–25 mm), and was encountered in 120 patients. Intra- and inter-observer variability of measurements were not significant. Fracture healing time averaged 10 weeks (range 6–20 weeks) and 5.3% of patients presented delayed union. Thirty-four patients (25.8%) were unsatisfied with the result. The mean Constant score was 84 (range 62–100). Forty patients were having pain, and 21 had shoulder function impairment. Shortening > 14mm was statistically associated with unsatisfactory results. Conclusion: Clavicle is an important element in the integral functional mobility of the shoulder and malunion after fracture could lead to unsatisfactory results. We describe a simple, reliable method of Clavicular length-shortening evaluation and we report the results following successful conservative management. Identification of those patients likely to have poor results after conservative treatment, would give the opportunity for alternative treatment modalities. Further prospective randomised trials are necessary

We evaluated the long-term results of 109 tibial plateau fractures, 61 treated by skeletal traction and early knee movement and 48 treated by surgery, at an average follow-up of 70 months. The functional results were much the same, though meniscectomy had been performed in almost half of the surgical patients. Time in bed and duration of hospital stay were clearly shorter after surgery (p less than 0.0001). We concluded that conservative management is a valid alternative to surgery, but should probably be reserved for cases where operation is undesirable. Future studies should compare surgery without meniscectomy and conservative treatment using cast braces to reduce the time in traction

Objective: To evaluate the functional outcome of the shoulder following Neer reconstruction with a conservative rehabilitation regime. Background data: Fractures of the proximal humerus following major or minor trauma are very common. The management of 3 and 4 part fractures of the shoulder with or without dislocation presents a challenging problem to the Orthopaedic Surgeon. Neer reconstruction remains a gold-standard operation. Standard rehabilitation regime is early mobilization to prevent the development of stiffness of the shoulder. However, an aggressive early rehabilitation may lead to non-healing of the greater tuberosity. Methods: Between Dec 96 to Jun 03, 40 patients with three or four part fracture of shoulder underwent Neer reconstruction and a conservative rehabilitation regime at our centre (age range of 39–87 with a mean of 66). Patients were kept in a sling for 3 – 4 weeks before physiotherapy was commenced. They were reviewed at least 1 year postoperatively for assessment of pain and range of movement. X-Rays were taken to investigate union of the greater tuberosity. For the purpose of this study all patients were recalled and reassessed with Constant-Murley scoring system. Results: Three patients died after the one year review, one patient lost to follow up. In 12.8% of the patients (mainly elderly, with mean age of 78.8) the greater tuberosity failed to heal. In those who the greater tuberosity healed mean elevation was more than 130, and mean external rotation was 40. Conclusion: Postoperative immobilization did not result in excessive stiffness and excellent functional results were achieved, especially in those younger than 70 years of age. However tuberosity union could not be guarantied in very old patients

Background: Acute traumatic rupture of the Tendo-Achilles is a common problem. Review of the published literature shows a conflict between surgical and non-surgical management. Primarily, surgical treatment has repeatedly been shown to have a lower re-rupture rate compared with conservative treatment. However, it is associated with a higher rate of other complications, principally infective soft tissue complications. Debate concerning the method and duration of conservative treatment regimens also remains. Methods: We aimed to assess the effect of knee position on the gap in acute tendo-Achilles ruptures. Our null hypothesis was there is no difference in tendon gap with variation of knee position. Patients with a history and examination consistent with an acute rupture were collected prospectively. They were imaged by the same consultant musculoskeletal consultant radiologist using ultrasound. Tendon gap was measured with the foot in neutral and full tolerable equinus with the knee both flexed to 90° and fully extended. A pilot study of 10 patients was used to provide data for a power calculation and consequently a total of 25 patients were recruited. Results: All patients had their clinical diagnosis confirmed and tendon gap measured in each of the 4 positions. A paired t-test was used to compare mean differences between each position. This confirmed there was no significant difference in the tendon gap with the knee flexed or extended providing the foot is in full equinus. This may have considerable implications on the rationale behind conservative treatment and splinting of acute tendo-Achilles ruptures

Purpose. Femoroacetabular impingement syndrome (FAI) is a common cause of hip and groin pain in young adults. Physiotherapy and surgery have both been used to treat FAI syndrome, but there is no robust evidence of comparative effectiveness. UK FASHIoN compared the clinical and cost-effectiveness of arthroscopic hip surgery (HA) versus best conservative care in patients with FAI syndrome. Methods. UK FASHIoN was a pragmatic, multicentre, 2 parallel arm, superiority, randomised controlled trial in patients with FAI syndrome. Eligible patients were over 16 without radiographic signs of osteoarthritis, deemed suitable for arthroscopic FAI surgery. Participants were randomly allocated to HA or Personalised Hip Therapy (PHT - a physiotherapist-led programme comprising 6 to 10 sessions). The primary outcome measure was hip-related quality of life using the patient-reported International Hip Outcome Tool (iHOT-33) at 12 months. Secondary outcomes included EQ5D5L, SF12, adverse events, and cost-effectiveness. Primary analysis compared differences in iHOT-33 scores at 12 months by intention to treat. Results. 348 patients were randomised. Time to surgery was 132 days (SD71) versus 47 days (SD52) to PHT. 92.5% were followed-up at 12 months. Baseline mean iHOT-33 scores were 39.2 (SD21) and 35.6 (SD18) in the surgery and PHT groups, and at 12 months 58.8 (SD27) and 49.7 (SD25) respectively. Mean scores in both groups improved over 12 months, but the mean iHOT-33 score increased more in those allocated to HA than to PHT, with an adjusted mean difference of 6.8 points (95% CI 1.7,12.0 p=0.009). One HA patient developed an infection requiring further surgery. Mean overall costs were £3713 for HA and £1283 for PHT. Conclusions. Hip arthroscopy and best conservative care both led to improved hip-related quality of life in patients with FAI syndrome. At 12-month follow-up, improvement was greater in those allocated to hip arthroscopy

1. The treatment of Bennett's fracture is reviewed and the relative merits of conservative and operative treatment is considered. 2. A closed method of treatment is described and a series of thirty-one patients so treated is analysed. There were twenty-nine successful results. 3. It is urged that conservative treatment is the method of choice, and that operative measures should be reserved for the occasion when closed methods have failed

Study Design: Prospective Cohort Study. Objective: To describe the natural history of a cohort of patients with osteoporotic vertebral fractures treated conservatively with bedrest and a Taylor brace. Summary of Background Data: Interest is growing in minimally invasive techniques to treat vertebral fractures in the elderly population. Amongst the benefits mooted are relief of pain and prevention of deformity. However limited background data is available concerning the long-term outcome of such patients treated conservatively. Patients and Methods: All patients admitted to our institution over a five-year period following a vertebral fracture were identified (n=223) Of these, 61 were suitable for inclusion in the study. Following departmental approval all patients were contacted by phone and invited to participate in the study. Patients were examined in the clinic, plain radiographs were performed and the Oswestry pain score, a visual analogue pain score (VAS), and SF-36 questionnaire were completed. Patients over 65 years, involved in minor trauma without neurological deficit were included. Patients over 65 years who were involved in major trauma or non-Irish residents were excluded from the study. Results: Mean patient age at the time of injury was 72.1 years. Mean duration of follow up was 8.2 years with a minimum follow up of 5 years. Seven patients were lost to follow up. Of the remaining fifty-four patients, five had died since their admission. According to family members none had any pain or neurological symptoms related to their spinal injuries. Forty patients attended the clinic for review while nine completed telephone questionnaires. Two patients had a clinically evident kyphosis. The mean range of anterior flexion was 78.9° ± 15°. The mean VAS pain score was 2.2 ± 2.0. No significant correlation existed between the magnitude of the initial vertebral collapse and the Oswestry or SF-36 scores. Physical Function and Bodily Pain subsets of SF-36 were no different to an age matched Irish population. No significant further vertebral collapse was noted on radiographic follow up. A small cohort of patients did develop chronic back pain. These patients’ outcome could not be predicted on the basis of initial radiographs. Conclusion: This study supports conservative management: most patients recovered normal function and suffered little long-term pain. It was not possible to predict which patients would develop chronic back pain on the basis of initial radiographs. This calls into question the indications for undertaking vertebroplasty or kyphoplasty in the treatment of such patients

The management of distal humeral fractures in low-demand patients with osteoporotic bone remains controversial. Total elbow arthroplasty (TEA) has been recommended for cases where achieving stable ORIF can be difficult. The ‘bag of bones’ technique, (early movement with fragments accepted in their displaced position), is now rarely considered as it is commonly believed to confer a poor functional result. The aim of this study was to present the short- and medium-term functional outcomes following the primary conservative treatment of distal humeral fractures in elderly and low-demand patients. We carried out a retrospective case note and radiograph review of all patients (n=40) aged 50 years or more, with distal humeral fractures treated conservatively at our institution over a six-year period. Short-term function was assessed using the Broberg and Morrey (B&M) score. Medium term function was assessed by telephone interview (n=20) using the Oxford Elbow Score (OES), QuickDASH and a pain questionnaire. The mean post-injury B&M score improved from 42 points at 6 weeks to 67 points by 3 months. By four years, surviving patients had a mean OES of 30 points, a mean QuickDASH of 38 points, and 95% reported a functional range of elbow flexion. Those with fracture non-union experienced greater pain on repetitive elbow activities, but no difference in rest pain, compared with patients whose fractures had united. The cumulative 1-year rate of fracture union was 53%, while the 5-year mortality approached 40%. Conservative management of distal humeral fractures confers a reasonable functional result to the patient whilst avoiding the substantial surgical risks associated with primary ORIF or TEA

Background: Interest is growing in minimally invasive techniques to treat fractures in the elderly population. Amongst the benefits mooted are relief of pain and prevention of deformity. However little background data is available concerning the long-term outcome of such patients treated by either conservative or surgical means. Aim: To describe the natural history of a cohort of patients with osteoporotic vertebral fractures treated conservatively with bed rest and a Taylor brace. Patients & Methods: All patients admitted to our institution over a five-year period following a vertebral fracture were identified. A total of 223 patients were admitted over the study period. Of these, 61 were suitable for inclusion in the study. Following departmental approval, all patients were contacted by phone and invited to participate in the study. Patients were examined in the clinic, plain radiographs were performed and the Oswestry pain score, a visual analogue pain score (VAS), and SF36 questionnaire were completed. Inclusion Criteria:. Patients over 65years at time of injury. Minor trauma e.g. minor fall. No neurological deficit. Exclusion Criteria:. Patients over 65 years who were involved in major trauma. Non-Irish residents. Results: Mean patient age at time of injury was 72.1years. Mean duration of follow up was 8.2 years with a minimum follow up of 5 years. Seven patients were lost to follow up. Of the remaining fifty-four patients, five died since their admission. According to family members, none had any pain or neurological symptoms related to their spinal injuries. Forth patients attended the clinic for review while nine completed telephone questionnaires. On examination, two patients had a clinically evident kyphosis. The mean range of anterior flexion was 78.9 + 15. The mean VAS pain score was 2.2 + 2.0. No significant corrleation existed between the magnitude of the initial vertebral collapse and the Oswestry of SF36 scores. No significant further vertebral collapse was noted on radiographic follow up. A small cohort of patients did develop chronic back pain. These patients’ outcome could not be predicted on the basis of initial radiographs. Discussion: Our study supports conservative management: most patients recovered normal function and suffered little long-term pain. It was not possible to predict which patients would develop chronic back pain on the basis of initial radiographs. This calls into question the indications for undertaking vertebroplasty or kyphoplasty in the treatment of such patients

This paper reports a prospective study of 72 consecutive patients with fractures or fracture-dislocations of the upper end of the humerus, treated during 1981. Most were elderly and treatment was conservative. Of the 72 patients 64 were followed up for a period of six months. Observations were made on the type of fracture, the speed and pattern of recovery of shoulder movements, on the time of commencement of physiotherapy, and on its duration. We found that with conservative treatment alone, 94% of our patients had good or satisfactory results at six months from injury. The criteria for manipulation are discussed and the literature is reviewed

Purpose: We present the midterm results of conservative treatment of upper (atlas and axis) cervical spine injuries and we propose a CT-based radiological follow-up study. Material and Methods: In a 12 year period (1990–2001), 45 patients (33 male and 12 female) with a mean age 37.2 years (range 15–75) were presented with an acute injury of the upper cervical spine. There were 19 fractures of the atlas (8 Jefferson’s fractures, 6 isolated lateral mass fractures and 5 posterior arch fractures) and 26 axial fractures (12 odontoid fractures, types I–III according to Anderson’s classification and 14 traumatic spondylolisthesis, types I–II according to Effendi classification). Twenty (20) patients were immobilized using halo-vest and 25 Minerva orthosis. Two (2) patients presented with Brown-Sequard syndrome. All patients were retrospectively reviewed and had clinical and radiological follow-up study (plain films and CT spiral reconstruction films). Mean follow-up was 6.2 years. Mean immobilization time was 3.8 months range. Results: Patients with incomplete neurological lesion did not recover. One patient with an isolated atlas lateral mass fracture, developed a hemiparesis during his hospitalization, which was partially resolved. In the final follow-up study, all patients presented a stable upper cervical spine, on the dynamic flexion/extension plain films. In the final CT spiral reconstruction films, fracture line was evident in 12 patients (27%), while atlantoaxial joint incongruity was obvious in 5 patients. Seven (7) patients (16%) complained for residual neck pain and stiffness and presented reduced range of motion. Conclusion: Conservative treatment of atlantoaxial injuries is effective and offers a stable upper cervical spine. Solid fracture union is not always present. CT spiral reconstruction is very helpful in detecting transverse ligament efficacy and atlantoaxial joint incongruity

Background: Reviews have showed none or little efficacy of passive conservative treatment modalities for patients with sciatica, reviews on surgery are conflicting. Cohort studies have shown high efficacy of active conservative treatment for patients with sciatica. The aim was to evaluate the efficacy of two active conservative treatment programs to patients with severe sciatica. Methods: The study was a prospective single-blind randomized clinical controlled trial of 181 consecutive patients with radicular pain below the knee. The patients were examined at baseline, 8 weeks later at post treatment follow-up, and at one year follow-up. In both groups treatment consisted of thorough Information concerning anatomy, pathogenesis, how discs heal without surgery, and Advice and encouragement to stay as active as possible, and optional medication. Then either Symptom guided exercises or Sham exercises. Results: All patients experienced a highly significant and clinically important improvement in global assessment, functional status, pain, vocational status, and clinical findings. The Symptom guided exercises + Information + Advice to stay active group (SYMIA) was significantly superior to the Sham exercises + Information + Advice to stay active group (SHAMIA) with regards to global assessment, clinical findings, sick leave and vocational status both at end of treatment and one year follow-up. There was a borderline significant difference in leg pain at end of treatment, and no difference was found in RMQ and EQ-5D. Conclusion: Patients who had symptoms and clinical findings which would qualify them for surgery in most hospitals improved greatly with active conservative treatment. Although the patients had greater faith in the SHAMIA before treatment, the SYMIA treatment was superior in most outcomes

All tibial shaft fractures treated at one hospital during a five-year period were studied in a prospective trial. Ninety-one displaced fractures in adults were treated using a conservative policy that included early bone grafting when indicated. Sound bony union was obtained in all cases. Those that healed primarily took on average 16.3 weeks whereas the 24 per cent that required bone grafts took 35.1 weeks. The number of complications, most of which were minor, was considered acceptable. It is concluded that provided early bone grafting is performed when necessary, a basically conservative policy of treatment is satisfactory; bony union of all displaced tibial fractures is achieved in a reasonable period of time

Chronic rotator-cuff syndrome with impingement is satisfactorily treated by acromioplasty by both open and arthroscopic techniques, but the Neer operation with deltoid detachment requires a prolonged rehabilitation. Arthroscopic acromioplasty reduces recovery time but is a difficult procedure. McShane, Leinberry and Fenlin (1987) described a conservative open anterior technique with good results and shortened rehabilitation. A similar technique has been used in 25 patients with an average age of 46 years. After a mean follow-up of 24 months, 80% were very satisfied and none was dissatisfied. The average recovery times were 2.7 weeks for activities of daily living, 1.9 months for return to work and 3.7 months for all activities including overhead manual labour

Purpose: Between January 1975 and December 2000, 498 cases of sarcoma of limb bones were treated by our multi-disciplinary team. Mean patient age was 27.1 years. Mean tumour size was 13.1 cm. Histology revealed osteosarcoma (n= 231), chondrosarcoma (n=118), Ewing sarcoma (n=104), MFH (n= 25), fibrosarcoma (n=12) and diverse tumours (n=8). The most frequent localisations were: femur (n=203), pelvis (n=98), tibia (n=86), humerus (n=60). Metastasis was present in 64 cases when first seen by our team. The histological resection was wide in 295 cases, marginal in 185 and contaminated in 18. Adjuvant treatment was adapted to patient age, histology and tumour localisation. Postoperative radiotherapy (34 to 50 Gy) was given for certain adults with osteosarcoma or Ewing tumours who had little histological response to preoperative chemotherapy or who had a marginal or contaminated resection. Results: Median follow-up was 12 years. Two hundred fifty-two patients were living and disease free, eight were still under treatment, and 238 had died of their disease or treatment complications. There were 35 cases of local relapse, most of them (n=26) in referred patients, particularly after insufficiently effective chemotherapy. Complications were mainly deep infections (n=42). Secondary amputation was required for 24 patients (5%). Functional outcome at last follow-up was excellent in 52% of the patients, good in 35%, fair in 7% and unsatisfactory in 6%. Outcome depended basically on tumour size and localisation and deteriorated with infectious complications and radiotherapy. Conclusion: 1. In our series, conservative surgery was performed in 95% of the cases, even for large tumours with fractures or for young children. 2. Functional outcome was better after conservative surgery: more than 85% excellent or good function. 3. Risk of local relapse was 2% for patients seen for initial diagnosis of high-grade malignant sarcoma. For patients with low-grade malignant tumours, or those who could not be given effective chemotherapy, the risk of local relapse was higher. 4. Radiotherapy improved local control for Ewing sarcomas and mesenchymatous chondro-sarcomas but its effect could not be assessed for the other tumours. As most of the secondary amputations and most of the poor functional results were observed in patients given complementary radiotherapy, this therapeutic modality, should, in our opinion, be avoided. 5. Preoperative chemotherapy being potentially dangerous for poor responders when the preoperative phase is continued too long, we advocate one month of preoperative chemotherapy for osteosarcoma and six weeks for Ewing sarcoma. This should be sufficient to allow conservative surgery (reduced tumour size) and chemotherapy (precise dose and protocols)

Objectives: To report the outcome and comparison of calcaneum fracture managements for intra-articular fractures. Methods: A prospective study of the patients with intra-articular calcaneum fractures in the foot& ankle unit of a busy trauma hospital. All the patients were followed up with the calcaneal fracture score. We compared the outcome of surgical management Sanders type 2 (Group A) and type 3 (group B) fractures with conservative treatment (group C) at 2 years and assessed the medium term outcomes of groups A and B. Group C were a consecutive series of patients recruited to the study later than A and B, hence the smaller number in that group. Results: 126 patients were included in our study. There were 70 in group A, 38 in group B, and 18 in group C. Mean follow-ups for the groups were A=6y, B=5.5y and C=2.34y. Mean two-year scores for the groups were A=68.13, B=63.78, and C=51.36, with statistically significant differences between groups A and C (P=0.0006), and between groups B and C (P=0.04), but no significant difference between groups A and B. At medium-term follow-up (> 5 years), the scores for group A and B were 77.06 and 63.66 respectively. There were 7 deep, 5 superficial infections and 32 metalwork removals in total. Conclusion: On comparing the medium term outcome to the two-year one, group A showed some improvement and group B stayed the same. In this series, there was a better outcome at two years with surgical treatment than conservative treatment

Purpose: To analyse middle-term outcomes of treatment of patients with congenital luxation of hip using modified overhead traction. Material and Methods: During the years 1991–2001, a total of 116 patients (138 hip joints) were treated. The group comprised 99 girls and 17 boys with the average age 4.7 months (ranging from 1.5–11 months). Patients were divided into two subgroups: patients who have been treated at our department from the determination of the diagnosis and those referred to our department from other facilities after unsuccessful conservative therapy. Only those patients were evaluated in whom the traction therapy was completed at least 2 years ago, the mean follow-up period was 4.5 years (2–10). After the initial preparatory horizontal traction, we moved to a 4-week overhead regimen wherein we increased the abduction by 10 degrees every five days. After completing the dystraction, every hip joint was examined using arthrography and where the reposition was possible, the therapy continued with the fixation in plaster spike for 6 weeks. Pavlik harnes were used for the final phase of the treatment. Results: In the group of primarily treated patients, reposition was successful in 78 out of 91 hip joints (85.7%). In another 4 hip joints (4.4%), reluxation occurred after an average period of 3.5 weeks after the removal of the spike. Nine hip joints (9.9%), 7 of type IV and 2 of type IIIB, were non-repositionable. Much worse results were achieved in the group of patients who received previous treatment. Only 12 hip joints (25.5%) were maintained permanently repositionable but neither of them was of type IV. Reluxation within two weeks after the removal of the fixation occurred in another 5 hip joints (10.6%). A total of 30 hip joints (63.9%) could not be reposed due to arthrographic findings of reposition obstacles. All these patients were admitted for treatment after the 6th month of age. We have observed no case of avascular head necrosis in the group of 90 patients who received conservative treatment. Conclusion: Traction therapy is a safe and mild method of treatment for congenital luxation of the hip joint. The rate of success of the therapy depends on the sonographic findings and age of patients at the beginning of therapy. Considerably worse results are achieved in the group of patients who have already received unsuccessful inadequate treatment

Aims

The aim of this study was to review the current evidence surrounding curve type and morphology on curve progression risk in adolescent idiopathic scoliosis (AIS).

Background: Traditionally, non-displaced scaphoid fractures are considered by most as stable with predictable rates of healing with conservative treatment. There is a current trend in orthopedic practice, however, to treat non- or minimal displaced fractures with early open reduction and internal fixation. This trend is not evidence based. In this systematic review and meta-analysis, we pool data from trials comparing surgical and conservative treatment for acute scaphoid fractures, thus aiming to summarize the best available evidence. Methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, EMBASE, CINAHL and reference list of articles, and contacted researchers in the field. We selected eight randomized controlled trials comparing surgical versus conservative interventions for acute scaphoid fractures in adults. Data were pooled using fixed-effects and randomeffects models with standard mean differences (SMD) and risk ratios for continuous and dichotomous variables respectively. Heterogeneity across studies was assessed with Forest plots and calculation of the I2 statistic. Results: Four-hundred seventeen patients were included in eight trials (205 fractures were treated surgically and 212 conservatively). Most trials lacked scientific rigor. Four studies assessed functional outcome with validated physician- and patient-based outcome instruments. With the numbers available (200 patients), we found a significant difference according to our primary outcome measure, standardized patient-based outcome in favor of surgical treatment (p< 0.0001). With regard to our secondary parameters, we found heterogeneous results that favored surgical treatment for grip strength, time to union and time off work. In contrast we found no significant differences between surgical and conservative treatment for pain, range of motion, rate of nonunion, malunion, and infection, rate of complications, and total treatment costs. Conclusions: Patient-rated functional outcome and satisfaction as well as time to return to function favored surgical treatment for acute scaphoid fractures. However, there is no evidence from prospective randomized controlled trials on physician-rated functional outcome, radiographic outcome, complication rates and treatment costs to favor surgical or conservative treatment for acute scaphoid fractures

Operative treatment of osteoporotic vertebral fractures seems to result in higher primary costs compared to conservative treatment. However it is still unclear whether the inpatient related follow-up costs don’t result in a different outcome. The aim of this analysis was a nationwide comparison of spine related inpatient treatments after balloon kyphoplasty versus conservative treatment of balloon kyphoplasty patients. Materials and Methods: 110 patients after conservative treatment and 141 patients after balloon kyphoplasty treated primarily between 2002 and 2005 in one center were followed up via a nationwide analysis of spine related inhospital treatment. Data from the Austrian DRG-system, which includes all inpatients treated in Austria have been used to identify admission of the target population between 2002 and 2006. Because no unique patient identifier is available in the data set, a matching according to data of birth, gender and postal code was used. Outpatient visits are not included. From these data the number of admissions, the length of stay and the scores can be determined. Furthermore each admission was classified as spine related or not. To calculate the exact follow up times the data were matched against the Austrian death registry. If a patient has died this data was used to calculate the follow up time otherwise December 31st 2006 was used. The mean age of the conservative group was 75.49 and of the kyphoplasty group 71.16 years. The total follow up time was 324.55 years(mean +standard deviation 2.92+−1.40) for the conservative and 354.25 (2.53+−0.96) for the kyphoplasty group. The shorter mean follow up interval for the kyphoplasty group is due to the fact that in the years 2004 and 2005 more patients have been treated by kyphoplasty. Results: The mean number of admissions in the kyphoplasty group is 0.779 or 0.308 per follow up year whereas in the conservative group these figures are approximately twice, namely 1.757 and 0.601. Considering the average length of stay the kyphoplasty group shows less inhospital days (9.2 per patient or 3.6 per follow up year), whereas in the conservative group this is 14.4 and 4.6 inpatient days. Finally the scores per admission in the follow up period are lower in the kyphoplasty group (3146 and 1243 DRG related treatment points) whereas in the conservative group these values are 3824 and 1308. Conclusion: These data show a strong superiority of kyphoplasty compared to conservative treatment of spine problems based on the data of one big hospital in Austria where 251 patients have been treated between 2002 and 2005. We demonstrate a long term superiority of balloon kyphoplasty compared to non-surgical treatment regarding inpatient treatments

Background: The Achilles tendon is the strongest and thickest tendon in the human body, it is very commonly injured with significant clinical implications. The treatment of Achilles tendon rupture is a matter of controversy in orthopedics and sports medicine. Surgical repair compared with conservative treatment is debated constantly in the literature, without a conclusive decision. The diagnosis of Achilles tendon rupture is based usually on clinical examination, and may be reinforced by ultrasound or magnetic resonance imaging. The present study has been conducted in order to determine whether an ultrasound examination performed at the time of injury could be useful in deciding how to treat the patient. Patients: Over a period of 5 years we treated 26 patients who had a clinical presentation of ruptured Achilles tendon with ultrasound diagnosis of either a partial tear or a full tear. Patients who were diagnosed by ultrasound as having a full tendon tear were operated on, and were not included in this study. Eight patients had partial tear of the tendon, six had a tear of the musculotendinous region, and twelve had a proximal tear. All patients were treated by means of a cast or a dressing, with limitation of weight bearing. The follow-up period ranged between six months to three years after the injury, and included up-to-date functional evaluation. Results: Eighteen patients were available for evaluation. Excellent functional results were reported by five patients, twelve patients reported good results, and one patient complained of a bad result. None of our patients needed delayed surgery, and only one suffered from re-rupture of the tendon during his rehabilitation, and was treated conservatively with good results. No correlation was found between the location of the tear and the functional results. Conclusions: 1. Ultrasound is an important and accurate tool in the diagnosis of Achilles tendon tear and is helpful in choosing the appropriate treatment. 2. Partial tear of Achilles tendon is not an indication for operative treatment, even when the clinical examination (Thompson test) is positive. The outcome of conservative treatment in this situation is as good or even better than surgical treatment

Rocker bottom deformity may occur during the conservative treatment of idiopathic congenital clubfoot. Between 1975 and 1996, we treated 715 patients (1120 clubfeet) conservatively. A total of 23 patients (36 feet; 3.2%) developed a rocker bottom deformity. It is these patients that we have studied. The pathoanatomy of the rocker bottom deformity is characterised by a plantar convexity appearing between three and six months of age with the hindfoot equinus position remaining constant. The convexity initially involves the medial column, radiologically identified by the talo-first metatarsal angle and secondly by the lateral column, revealed radiologically as the calcaneo-fifth metatarsal angle. The apex of the deformity is usually at the midtrasal with a dorsal calcaneocuboid subluxation. Ideal management of clubfoot deformity should avoid this complication, with adequate manipulation and splinting and early Achilles’ percutaneous tenotomy if plantar convexity occurs. Adequate soft-tissue release provides satisfactory correction for rocker bottom deformity. However, this deformity requires more extensive and complex procedures than the standard surgical treatment of clubfoot. The need for lateral radiographs to ensure that the rocker bottom deformity is recognised early, is demonstrated

Purpose: Amputation is often proposed for malignant tumours of the distal tibia. The purpose of our study was to report outcome and complications after conservative treatment of osteosarcoma of the distal tibia. Material and methods: Eight patients, four boys and four girls aged 8 – 16 years (mean 12 years) were managed conservatively with high-dose methotrexate chemotherapy for osteosarcoma of the distal tibia between 1983 and 1998. Wide resection was performed in all cases and one patient had a lung metastasis. Mean length of resection was 13 cm (9–19). Tibiotalar reconstruction arthrodesis was performed in seven patients. Tibial grafts and a centromedullar nail associated with fibulotalar arthrodesis with screw fixation were used in four patients. Plate fixation was used in two, and one patient had a cement spacer while waiting for biological reconstruction. After surgery, the patients were immobilised in a plaster cast for three to six months. Weight bearing began two to four months after surgery. Results: Resection was wide in four cases, marginal in three , and contaminated in one. Four patients responded well to chemotherapy and four responded poorly. Outcome was assessed at a mean follow-up of 5.5 years (2–17 years). At last follow-up, six patients were in remission, and two had died, including one after local recurrence despite amputation. Three patients had a deep infection which cured in all three without surgery. Two revisions were required in one patient with nonunion before achieving a solid union. All the patients who had a tibiotalar arthrodesis progressively developed nearly normal “ankle” function subsequent to progressive sub-talar hypermobility. The mean MSTS score was 27.7/30 (range 22 – 30). Discussion: Conservative management of osteosarcoma of the distal tibia appears to be feasible and provides excellent functional results despite an important risk of infection. Wide surgical margins requires a good response to chemotherapy. In case of doubt, reconstruction must avoid contaminating the rest of the tibia in order to allow secondary amputation if needed

Pyomyositis is a primary pyogenic infection in skeletal muscle, often progressing to abscess formation. It is rare in temperate climates and generally deep-seated within the pelvis with non-specific clinical features, making diagnosis difficult. Magnetic Resonance Imaging (MRI) is highly sensitive for muscle inflammation and fluid collection and with its increasing availability is now the investigation of choice. Treatment of pyomyositis abscess has traditionally been with incision and drainage or guided aspiration followed by a prolonged course of antibiotics, although there are sporadic reports of cases treated successfully with antibiotics alone. From our 20 year database of over 16000 paediatric orthopaedic admissions we identified only 3 cases with MRI-confirmed pyomyositis abscess. These were all in boys (aged 2-12) and affected the gluteal, piriformis and adductor muscles. Despite the organisms not being identified, each patient was treated successfully with a short (4-7 day) course of intravenous antibiotics followed by 2-6 weeks of oral therapy. There were no recurrences or complications and all made a full recovery. We propose that uncomplicated pyomyositis abscess in children may usually be managed conservatively without the need for open or percutaneous drainage

Evaluating the effectiveness of conservative treatment of odontoid fractures, from 1997 to 1999 we reviewed 22 cases. All were treated first in halo traction and subsequently by halo thoracic brace immobilisation. We used Anderson and D’Alonzo’s classification of types I to III. The mean follow-up time was seven months. Initial displacement was measured radiologically and union was evaluated. In type-II fractures, the incidence of pseudarthrosis was 40%. Fractures with more than 5 mm of initial displacement and more than 10° angulation all went on to nonunion, suggesting that type-II fractures should be treated by internal fixation

Today more and more papers are published about the operative treatment of femoral fractures in children and even uncomplicated and isolated fractures are treated by using elastic nails, plates or an external fixator. Advantages are said to be a shorter stay in the hospital, easier handling by parents and nurses, less costs and better control of rotational disorders, and without complications from anaesthesia or an operation. We summarised our results in treating conservatively 50 femoral fractures in 49 children treated between 1992 and 1997. The mean age was 6.2 years; male/female ratio was 30/19. We included five children with minor polytraumatisation (including one girl with a bilateral femoral fracture) and two children with complicated fractures (grade I). Children younger than three years of age were treated by Bryant-traction (18), and children older than three years were treated by Weber-traction (23). In both groups the callus was palpable after 2 to 3 weeks and a “one-legged” hipspica-plaster-cast was applied. Full weight bearing was permitted. Children needing surgery (major polytraumas, brain damage, etc.) were excluded. Seven cases had a fracture without dislocation and were treated by early casting. One boy was treated by Russell-traction. An unacceptable dislocation of the fracture still existed in two cases after one week with Weber-traction. Peroperatively, interposition of the soft tissues appeared to be the reason. There were no problems of alignment and rotation, but differences in leg length or problems in consolidation were seen in the group treated with Bryant- traction. In the Weber-traction group, the girl with the bilateral femoral fracture developed a mild endorotation in the left leg, but we saw no further complications. We think that these results in treating femoral fractures conservatively are satisfying and there is still a place for conservative treatment of femoral fractures in children. In our hospital we try to advance this type of conservative treatment by selecting cases that are appropriate for home traction, which is better for children and their parents and also less expensive for the Health Care System

Background: The incidence of proximal humeral fractures is increasing with time. There is continuing debate about the indications for surgical intervention for this relatively common injury. Baseline data on functional outcome is essential in order to study the effect of surgical intervention. Functional outcome scores provide reliable and valid judgments of health status and the benefits of treatment. During our preparation of a study proposal on this topic to the Health Technology Assessment Program recently, we noted the lack of such data on outcome scores in the current literature. Aim: To assess the functional outcome using the Constant and Oxford scores in patients treated conservatively for proximal humeral fractures. Methods: We prospectively studied 103 consecutive patients who were treated conservatively for proximal humeral fractures. Patient demographics, fracture type (Neer), hand dominance and comorbidity were recorded. Constant and Oxford shoulder scores were recorded 3 and 12 months post injury. Results: The average Constant shoulder score for males was significantly higher (better outcome) and the Oxford shoulder score significantly lower (better outcome) as compared to females. The scores were not affected by hand dominance. Although the raw scores tended to be worse with 3 or 4 part fractures the difference in the mean scores between the various Neer fracture types did not reach convential levels of significance. A trend towards lesser degrees of improvement in the outcome scores was noted with increasing age. The degree of improvement in the outcome scores was not affected by sex, limb dominance or fracture type (Neer’s classification). Conclusion: This study indicates the average behaviour of the Constant and Oxford scores with conservative treatment of proximal humeral fractures. This data should help with sample size and power calculations when studying interventions for this injury. We hope that this data will provide a baseline to help inform future study designs on proximal humeral fractures

We assessed arthroscopically 22 young athletes with an isolated acute posterior cruciate ligament (PCL) injury. Four had significant damage to the articular cartilage of the medial femorotibial compartment and were advised not to resume sports. Three underwent PCL reconstruction because of a reparable meniscal tear or instability. The other 15 were treated conservatively and resumed sport. At an average follow-up of 51 months, one had developed arthritic symptoms due to newly-developed severe chondral damage to the medial femoral condyle, but none of the other 14 had developed arthritic symptoms and most remained athletically active. Severe chondral damage should be seen at an early arthroscopy. Knees with an isolated injury to the PCL with concomitant articular damage may be successfully managed by conservative treatment

Costoplasty remains useful in the treatment of adolescent idiopathic scoliosis, rib hump and associated chest wall deformities. However traditional costoplasty increases morbidity and blood loss. We examine the feasibility and possible effectiveness of a more conservative costoplasty using an animal model. 4 fresh half Ovine rib cages from separate animals were obtained, stored at +4 °C and warmed to room temperature before testing. Each rib cage was randomly assigned to group 1, 2, 3 or 4. Ribs 2–10 were dissected out for testing. The ribs then underwent stepwise deconstruction according to their group. Beginning at the convexity, removing first the convex cortex, then the cancellous, then the cranial and caudal cortices to leave just the concave cortex. Testing for stiffness was by three-point bending on the concave side of each rib with the rib fixed at the head of the rib and 5 cm from the resected area. The ribs were deformed at a constant rate of 0.5 mm.sec . −. 1 up to a maximum load of 9.99 kg or until fracturing. Then stress was plotted against strain to find the Young's modulus of each group and statistics carried out with an ANOVA test. The ribs in each group were as follows: Group 1= control, group 2= 30 mm long convex side cortical bone removed 10 mm from lateral tubercle, group 3= convex, cortical and cancellous bone removal and group 4= removal of convex, caudal and cranial cortices with cancellous removal. The Young's Modulus of the groups were: 1= 3.38 N-m (+/− 0.84), 2= 2.65 N-m (+/− 1.58), 3= 1.55 N-m (+/− 0.55) and 4= 0.74 N-m (+/− 0.55). Groups 3 and 4 were significantly less stiff than group 1 (p< 0.01.) No ribs in groups 1, 2 and 4 fractured under the maximum load. 5/8 ribs in group 3 fractured before the maximum load was administered. By deconstructing the rib down to only the concave side it becomes significantly more flexible by approximately 4.5 times than the control Ribs. Coupled with its increase in flexibility it still retains its ability to withstand up to 10 kg of load without fracture. It may be possible to perform a costoplasty whilst preserving ventilatory integrity. This may improve rib hump correction, and curve correction due to increased flexibility of the stiff thoracic cage

Introduction: Primary surgical treatment has been recommended for unstable clavicular fractures if consequences of non-union or malunion have to be avoided. A prospective study was undertaken to evaluate the results of a conservative treatment of very unstable fractures of the middle third of the clavicle, with emphasis to very early mobilization. Material: Patients to be included in the study had to met the following criteria: 1) Fractures of the middle third of the clavicle, severely displaced or comminuted, 2) Closed injuries, 3) No neurovascular complications, 4) No pneumothorax or hae-mothorax and 5) No other injury in the ipsilateral upper extremity. Twenty-three patients with an average age of 24 years included in the study. Each patient evaluated with AP and 45-degree cephalad-tilted views. All patients treated with an arm sling and strongly instructed for early mobilization. All patients were evaluated in a weekly interval and assessed with the American Shoulder and Elbow Surgeonñs shoulder evaluation form. Results: The average follow up was 21.4 months. All fractures were consolidated and all malunited; but no patient had residual symptoms or functional impairment of the limb. On patient developed mild hypesthesia in the ulnar nerve territory. Conclusion: The extremely encouraging results of our study, within the bounds of the above-mentioned follow up, indicate that conservative treatment with very early mobilization may be considered as a valid therapy. However it is a concern the functional result in a longer follow up as well as the cosmetic result

Introduction: Hip fractures guidelines suggest that ‘all patients with fracture neck of femur should be operated upon as soon as possible (within 24hrs). Despite this different studies suggest that still 11% of hip fractures are treated conservatively (varies 3–37%). Aim: Our main aim was to find out whether there is a place for non-operative treatment as a definitive primary option in patients with significant medical comorbidity. We also wanted to audit best practice for conservative treatment in medically compromised patients and in those patients whose hip fractures are not suitable for surgical repair. Methods: We did this audit in 2007 collating information on 1010 hip fracture patients across 14 NHS hospitals in England. 50 out of 1010 (4.95%) patients were treated conservatively. We reviewed the records of these 50 patients (range 66–99, mean age 78 years) and looked at patient demographics, radiographic features, mobility, accommodation, cognition, and ASA class were recorded. Results: There were 17 males and 33 females patients managed conservatively in our study. Before injury, 37 (74%) were living at home and 13 (26%) were institutionalised. During hospitalisation, 4 became bedridden and 30 died (mainly due to medical comorbidities). Among these 50 patients, eight were deemed physically unfit for surgery by anaesthetists and two by medical consultants. The decision of conservative treatment was made by orthopaedic consultants in ten cases and by multidisciplinary team in four cases. Five patients refused surgery and five patients were palliative due to terminal illnesses. Patients who did not proceed to surgery (either treated conservatively by choice or presented at admission with complications) had significantly higher mortality rates (overall mortality rate 60 %) suggesting that they were physiologically much worse group of patients. Discussion: As the average life span of our population increases, some hip fractures are now treated non-operatively because of the possibility of severe or fatal complications due to surgery. Often, refusal of surgery by the patient or the patients’ family obligates the need for non-operative treatment. It is acceptable to postpone the surgery if the patients are medically unfit for these reasons (eg. acute cardiac event, patient dying, severe aortic stenosis, multi-organ failure). It is not considered appropriate if surgery is cancelled due to pyrexia, chest infection, borderline Hb or awaiting ECHO for murmur. Administrative or logistic reasons (eg. no HDU bed) needs to be looked at higher levels as well

We assessed the long-term (20 years) outcome of closed reduction and immobilisation in 19 patients with an isolated fracture of the posterior malleolus of the ankle treated at a single hospital between 1985 and 1990. The assessments used were an Olerud functional questionnaire score, physical examination using a loaded dorsal and plantar range of movement measurement, radiological analysis of medial joint space widening, the Cedell score for anatomical alignment of all three malleoli, and the radiological presence of osteoarthritic change. . There were excellent or good results in 14 patients (74%) according to the Olerud score, in 18 patients (95%) according to loaded dorsal and plantar range of movement assessment, in 16 patients (84%) as judged by the Cedell score, and for osteoarthritis 18 patients (95%) had an excellent or good score. There were no poor outcomes. There was no correlation between the size of the fracture gap and the proportion of the tibiotalar contact area when compared with the clinical results (gap size: rho values -0.16 to 0.04, p ≥ 0.51; tibiotalar contact area: rho values -0.20 to -0.03, p ≥ 0.4). Conservative treatment of ‘isolated’ posterior malleolar fractures resulted in good clinical and radiological outcome in this series at long-term follow-up.

Background

Optimal management of displaced intra-articular calcaneal fractures remains controversial. The aim of this prospective cohort study was to compare the clinical and radiological outcomes of minimally invasive surgery (MIS) versus non-operative treatment in displaced intra-articular calcaneal fracture up to 2-years.

The D.D.H screening programme until the second half of ’80 was based on the clinical Ortolani-Barlow’s manoeuvre at newborn age and by xray examination of the pelvis at three – four month old to discover hip joint anomalies that could be address at a future dislocation. Never less the so-called Dislocation of the Hip was a quite common pathology around Europe. The close reduction of a dislocated hip has been the treatment of choice in order to attempt to reduce a dislocated hip without surgical operation. Close reduction was preferred to be obtained after a period of skin traction on bed, at which a special frame were added, to perform a progressive gentle reduction gaining, in an average of three weeks time, complete abduction before applying a spica cast. Two main methods were used: reduction with the hips extended, abducted and internal rotated according to Sommerville- Petit and reduction in over head position with the hips flexed, abducted and external rotated. These two systems were designed to decrease the Avascular Necrosis of the femoral head that often occurs if the reduction was obtained during a sudden manoeuvre under general anaesthesia. Generally the correct position of the femoral head into the acetabular socket, at the moment to apply the plaster, was assessed by an arthrogram, to avoid the bad surprise of further dislocation due to false reduction after the traction period. The child so treated had to be followed during her/his growth to assess the development of acetabular roof and the position of the femoral head linked at the antiversion of the femoral neck. Any hip joint, in which acetabular index do not improve during growth, needs acetabular and femoral osteotomies to overcome these anatomical defects as cause of a persisting genetic defect. At the end of ’80, a deep change of the natural history of D.D.H. in Italy is related to the introduction of screening programme based on accurate clinical examination of the hip of the babies at the nursery, selection of babies with risk signs of D:D.H. such as clinical anomalies, instability of the hip at Ortolani-Barlow’s, familiarity for D.D.H. and breech delivery. The hips of those babies are immediately assessed by ultrasonographic examination according to Graf’s method. The general population, on the contrary, is examined by US between the second and the third months of age. The National Health Service encourages the US screening paying its cost. In this way the incidence of late-D.D.H. and late-dislocation is enormously decreased and the outcome of the pathology has been improved. The conservative treatment of the hip affected by different grade of anomalies early discovered trough US examination, in fact, are treated by simple harness in abduction for mild dyspalsia to plaster spica cast in human position if the hip is severely unstable and Ortolani positive. There are same rare cases of true Congenital Dislocation at birth that can not be conservatively reduced and it will be necessary to perform a open reduction generally when the ossified nucleus of femoral head appeares. Our experience:. From 1975, when our Children Orthopaedic Department was created in the Medical School of “Federico II” University of Naples and the first authors become the Chief, we admitted 374 patients affected by dislocation of the hip (F=308 – M= 66 F:M= 5:1) with a mean age of 7 and half months (min.4 mths.– max 20 mths). All these patients were put in traction on the Morel’s bed in order to attempt a close reduction in extended, abducted and internal rotated position according to Sommerville- Petit method. Average time of traction was 25 days (min. 7 max 38). 120 patients were undergone at an arthrographic examination in general anaesthesia. 46 patients did not achieve the reduction and were operated on. A spica cast were applied for 60 days followed by an harness in abduction. Total amount of time of treatment was a mean of 7 months (min 110 days max. 12 months). Residual dysplasia was observed in 48 patients that needed a further surgical procedure. The number of inpatient affected by D.D.H. were an average of 21 per year until 1990 to drop dramatically at 3 per year in the last decade. On the other hand the D.D.H. outpatient clinic increased. The selected babies examined were 6930 at an average age of 4 months old. All the babies were undergone to clinical and Us examination and classified according to Graf. Hip anomalies were seen in 630 babies. The treatment was related to clinical and Us observation. Simple abduction pillow or simple harness in abduction were used in hip clinically negative at Ortolani-Barlow’s manoeuvre and 2c or 2b type according to Graf.’s classification. Milgram harness or Coxaflex harness (Thamert –Burgwedel –Germany) or plaster spica cast in “human position” were applied in instable hip type D or worse and clinically positive at Ortolani-Barlow manoeuvre. 25 patients were hospitalised because affected by irreducible hip. Conclusion:. The experience that we have done over decades in treatment of D.D.H. confirms the assumption of Treadwell and Bell (1981) that claimed that D.D.H. screening deeply changed the natural history of D.D.H. The problem was to find a good screening test helpful to diagnose as soon as possible a pathological hip. Graf’s method, after a decade of scientific criticism, can be elected at a worth method to screen an infant hip. Screening program based on ultrasound and clinical examination decreases hospitalisation, cost and sequels of D.D.H. in term of surgical operation and degenerative arthritis of hip joint at least at a medium follow up. The hip that need to be hospitalised are the true congenital dislocated hip for which early diagnosis probably should not effect their clinical history. A danger is hidden in US screening. Ultrasonography has to be performed by a skill examiner and it has to be implemented by careful clinical examination with anamnestic recording of the data in order to obtain the best result of the D.D.H. screening program

Four military recruits with complete distraction-type stress fractures of the femoral neck were treated conservatively. The radiographic diagnosis was made within two weeks of the onset of symptoms and the activities of the patients were matched to the clinical and radiographic progress of fracture healing. None of the fractures displaced and union occurred uneventfully. Our experience suggests that prophylactic internal fixation of these fractures is not necessary

Introduction: The aim of this paper was to test the hypothesis that for hips affected with Legg-Calve-Perthes’ (LCP) disease under the age of 8 years, surgery does not affect the outcome. Methods: We performed a retrospective paired study of patients, who were diagnosed with LCP disease before the age of 8 years, to compare the radiological results after treatment between conservatively and surgicallytreated groups. One patient was selected from each group to create the pairs for this study. Each pair was strictly matched for gender, body mass index, age at onset, and stage at the first visit, Catterall and Herring grading and radiological at-risk signs. Each pair was assessed by comparing the values of five radiological measurements. Results: From a cohort of 345 hips diagnosed with LCP disease 14 pairs (28 hips) fitted the criteria. The radiological measurements, which showed a statistically better result in the surgical groups, were Mose’s method (p = 0.019), the Acetabular-Head Index (p = 0.034). There were no statistical differences in the Slope of the Acetabular Roof (p = 0.37), Articulotrochanteric distance (p = 0.17) and Stulberg grading (p = 0.2). 5 pairs had a better Stulberg result in the operative group. Three of these 5 pairs were less than 6.5 years at the time of their surgical procedure. Three pairs had a better Stulberg result in the conservative group. Six pairs had no difference between the groups. Discussion: We conclude that surgical treatment can improve the sphericity of the femoral head and provide greater acetabular cover than conservative treatment in hips of patients less than 8 years at the onset of LCP disease. However, the Stulberg grading was not affected. Our study supports the hypothesis that for hips affected with LCP disease under the age of 8 years, surgery does not affect the outcome

Introduction. Distal radius fractures (DRF) are a common injury in the A&E departments, being a major cause of disability of the upper extremity. The aim of this prospective study is to assess the possible association between objective physical variables such as wrist range of movement (ROM), radiological parameters, and upper extremity disability (measured by the DASH questionnaire), after conservative treatment of DRF. Patients and methods. 44 patients with non-operatively managed DRF were enrolled in a prospective cohort study from July 2007 till September 2009. Inclusion criteria: unilateral DRF in skeletally mature patients, treated non-operatively with closed reduction and cast. Patients who sustained a previous fracture of the wrist, or bilateral wrist fracture, or with dementia, were excluded. After the closed reduction and inmovilization of the fracture in the A&E department we asked the patients to complete the DASH questionnaire, referring to their baseline pre-fracture state. All fractures were classified according to the AO classification. After one year, 36 patients were still available for follow-up purposes. We assesed the following objective physical variables: ROM of both wrists: flexion/extension arc and pronation/supination arch. We recorded the following radiologic parameters: radial angulation, volar angulation and radial shortening. The patient-perceived results were measured by the DASH questionnaire, while pain was measured using the VAS scale. Statistical analysis was performed using the SPSS 15.0. Results. Average follow up: 13,39 months (range 12.3–16.43). Mean age: 62.5 years (18–91). 75% of the fractures were 23A and 24,1% 23B. Average pre-fracture DASH score was 19.6 and 42.1 at the end of follow-up. Radial tilt: 18.18°. Volar tilt: 3,35°. Radial shortening: 5,76mm. ROM for flexion/extension of the involved wrist: 103.6° and non-involved wrist: 131.2°. ROM for pronation/supination involved wrist: 145.7° and non-involved wrist: 173.8°. Post-fracture VAS score: 3.5. We didn't find any significant statistical correlation between the lost of ROM, neither with radiological malaligment nor with patient-perceived outcomes. But we found a significant association between items 24–28 of the DASH (except item 26) questionnaire and the VAS score. Conclusions. The results of the present study show that, conservative treatment of DRF seems to deteriorate the patient self-reported outcomes measured by the DASH questionnaire

BACKGROUND CONTEXT. Osteoporosis causes decreased bone mineral density, which predisposes to fragility fractures. Low-energy vertebral compression fractures are the most common type of osteoporotic fragility fracture. Prior studies have shown that only one-quarter of patients diagnosed with an osteoporotic fracture are referred or treated for osteoporosis. PURPOSE. To identify the rate of recurrent fractures after vertebroplasty and after the conservative treatment for patients aged 50 years and older who sustained low impact vertebral compressions fractures over a 6-month period. STUDY DESIGNED/SETTING. Prospective study. PATIENT SAMPLE. The sample included patients 50 years or older who had a low-energy vertebral compression fracture. The patients were divided into two groups: first group (n=24) - patients teated by vertebroplasty and the second group (n=34) - patients treated conservatory. There was no significant difference among the groups in terms of the vertebral levels or BMD. METHODS. Patients records were reviewed for fracture recurrence and in the same time we examined medical records for osteoporotic medication prescriptions, refferals to endocrinology and to dual-energy X-ray absorptiometry (DEXA) scans. RESULTS. Confounding factors of age at the procedure, sex and chronic steroids use were considered and found to have no statistically significant difference between the two groups and between those with fracture recurrence and those without fracture recurrence. Four vertebroplasty procedure resulted in a recurrent fracture within the first 6 months. In the patient group treated conservatory 8 patients sustained recurrent fractures. Patients with recurrent vertebral fracture didn't receive active osteoporosis treatment. Within 6 months after the fracture only 21% of patients were receiving active osteoporosis treatment. CONCLUSIONS. The incidence of recurrent fracture after vertebroplasty or after conservative treatment is substantial but have no statistically significant difference between the two groups. We consider that the recurrence rate is not related with the surgical intervention but is the result of natural history of the patient's osteoporosis because the patients do not understand the importance of initiating active therapeutic intervention for osteoporosis recommended by physicians

Introduction: The aim of our study was to assess any difference in outcome between non-surgical and surgical treatment of displaced calcaneal fractures. Materials and Methods: We studied 40 patients between 2000 to 2005 with displaced calcaneal fractures. Patients with significant co-morbidities were excluded. Two groups of 14 patients, surgery vs. no surgery were compared for age, sex, length of follow-up, fracture type by Essex-Lopresti classification and SF-36 outcome score. The non-surgical group underwent treatment with rest, ice, compression, elevation and the surgical group underwent fixation with an AO calcaneal plate through an extended lateral approach. Results: There was no statistically significant difference between the surgical and conservatively treated groups for age, sex, time since injury and fracture type according to Essex-Lopresti but a highly statistically significant difference in SF-36 outcomes between the two groups favouring surgically treated calcaneal fractures. Summary: Displaced fractures of the calcaneum are a significant injury affecting patients general health. In the literature controversy exists as to whether operative or non-operative treatment is better for this type of fracture. Conclusion: Although the numbers are small, our study favours operative intervention, if possible, for this controversial fracture

Aims: To explore potential predictors of functional outcome after conservative treatment of acute fractures of the base of the fifth metatarsal. These fractures are the most frequent fracture of the foot. The factors that influence final clinical outcome are rarely investigated. Regression analysis regarding this problem was never performed. Methods: The study design was observational and retrospective. Adults, conservatively treated for an acute fracture of the base of the fifth metatarsal included. All patients were given a plaster cast at the emergency department and were instructed not to bare weight (NWB) on the affected limb for at least one week. The further modalities of treatment were decided by individual surgeons according to their current clinical practice. A validated scoring system was used. Additional questions were asked about residual cosmetic and shoe problems and also about intensity of pain and the general feeling of comfort. The respective influences of factors on clinical outcome were examined using multiple linear and logistic regression modeling. Results: 38 patients (11 men, 27 women) were analysed. The mean age was 48 years. 6 had a Jones fracture, while 32 had a tuberosity avulsion fracture. The mean non-weight bearing period was 2 weeks and 4 days (range 1 to 5 weeks) while the cast was worn for a mean of 5 weeks and 3 days (range 1 to 10 weeks). Three Jones fractures and all the avulsion fractures were healed at the end of treatment. The mean follow-up time was 298 days, ranging from 51 to 603 days. The mean result of the ankle score at follow-up was 77.5 (range 20 to 100). Thirteen of the 38 patients reported problems in wearing shoes. Only 8 patients experienced cosmetic problems. The mean linear analogue score for pain was 2.34, that for general comfort was 8.11. Overall, the most significant predictors of poor functional outcome at final follow-up evaluation were increasing duration of NWB and longer follow-up time. Longer NWB was importantly associated with worse global score, pain, comfort and reported stiffness. Neither gender nor fracture type had any significant influence on the overall clinical outcome. Conclusions: The most important variable linked to final clinical outcome is the duration of the non-weight bearing period. Neither gender, age, length of casting nor even fracture type, had any significant influence on the overall clinical outcome. Therefore NWB should be kept to a minimum for acute avulsions