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

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

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.

Aims. The primary aim of this study was to establish the cost-effectiveness of the early fixation of displaced midshaft clavicle fractures. Patients and Methods. A cost analysis was conducted within a randomized controlled trial comparing conservative management (n = 92) versus early plate fixation (n = 86) of displaced midshaft clavicular fractures. The incremental cost-effectiveness ratio (ICER) was used to express the cost per quality-adjusted life-year (QALY). The Six-Dimension Short-Form Health Survey (SF-6D) score was used as the preference-based health index to calculate the cost per QALY at 12 months after the injury. Results. The mean 12-month SF-6D was 0.9522 (95% confidence interval (CI) 0.9355 to 0.9689) following conservative management and 0.9607 (95% CI 0.9447 to 0.9767) following fixation, giving an advantage for fixation of 0.0085, which was not statistically significant (p = 0.46). The mean cost per patient was £1322.69 for conservative management and £5405.32 for early fixation. This gave an ICER of £480 309.41 per QALY. For a threshold of £20 000 per QALY, the benefit of fixation would need to be present for 24 years to be cost-effective compared with conservative treatment. Linear regression analysis identified nonunion as the only factor to adversely influence the SF-6D at 12 months (p < 0.001). Conclusion. Routine plate fixation of displaced midshaft clavicular fractures is not cost-effective. Nonunion following conservative management has an increased morbidity with comparable expense to early fixation. This may suggest that a targeted approach of fixation in patients who are at higher risk of nonunion would be more cost-effective than the routine fixation of all displaced fractures. Cite this article: Bone Joint J 2019;101-B:995–1001

The primary aim of this study was to undertake a cost-effectiveness analysis (CEA) of acute fixation versus conservative management of displaced midshaft clavicle fractures. The secondary aim was to conduct a sensitivity analysis of patient characteristics that may influence a threshold of £20,000 per quality-adjusted life year gained (QALY). A CEA was conducted from a randomised control trial comparing conservative management (n=92) to acute plate fixation (n=86) of displaced midshaft clavicle fractures. The incremental cost effectiveness ratio (ICER) was used to express the cost per QALY. The short form 6-dimensional (SF-6D) score was the preference based index to calculate the cost per QALY. The 12-month SF-6D advantage of acute fixation over conservative management was 0.0085 (p=0.464) with a mean cost difference of £4,096.22 and resultant ICER of £481,908.24/QALY. For a threshold of £20,000/QALY the benefit of acute fixation would need to be present for 24.1 years. Linear regression analysis identified nonunion as the only independent factor to influence the SF-6D at 12-months (p<0.001). Conservatively managed fractures that resulted in a nonunion (n=16) had a significantly worse SF-6D compared to acute fixation (0.0723, p=0.001) with comparable healthcare cost at 12-months (£170.12 difference). Modelling the ICER of acute fixation against those complicated by a nonunion proved to be cost effective at £2,352.97/QALY at 12-months. Routine plate fixation of displaced midshaft clavicle fractures is not cost-effective. Patients with nonunion after conservative management have increased morbidity with comparable expense to those undergoing acute fixation which suggests targeting these patients is a more cost-effective strategy

This prospective study explores the outcomes of the Forth Valley Protocol (FVP) for the management of acute Achilles tendon ruptures. The protocol uses ultrasound as the primary mechanism to guide treatment. All patients presenting with acute tendoachilles rupture over a three-year period were included. Patients under 18 years of age, chronic ruptures, or prior surgery to the Achilles tendon were excluded. Patients with a gap ≤2cm had conservative management following an Early Rehabilitation Protocol (ERP) and >2cm underwent surgery (if an appropriate surgical candidate). Achilles Tendon Rupture Scores (ATRS) were obtained retrospectively. Fischer's exact test was used to determine statistical significance. 158 patients were included with a mean age of 53 (range 20–89). Ultrasound scans were obtained for 121 patients (76.5%), demonstrating a mean tendon gap of 1.61cm. 143 patients managed conservatively and 15 surgically. The overall re-rupture rate was 3.8% (n=6). All the re-ruptures occurred in patients treated conservatively, but this was not found to be statistically significant (n=6, P=1.0). The overall complication rate (excluding re-ruptures) was 1.9%. ATRS was comparable between both treatment modalities (P=0.382, 0.422), with a mean score of 86.6 in the conservative group and 81.4 in the surgical group. The FVP demonstrates low re-rupture and complication rates in line with other published studies. Patients with gaps ≤2.0cm on the ultrasound can be successfully treated conservatively with an ERP. This has potential benefits in terms improved patient outcomes, satisfaction, and preservation of resources

Sub-acromial decompression surgery (SAD) has been widely used to treat shoulder impingement. Its validity has been questioned in multi-centric clinical trials and dissatisfaction rates can be high (35%). It is difficult to predict which patients will benefit operatively as research into predictive factors is limited. The study aim was to conduct a root-cause analysis of reasons for dissatisfaction in a cohort of operated patients. All patients with SAD dissatisfaction in the local Upper Limb database between 2015-19 (n=74/296) formed our study cohort. Patients were scored on Oxford shoulder score (OSS), QuickDASH score, EQ-5D-3L (TTO+VAS) at weeks 26 and 52 post-operatively. Patients' clinical history, radiographs, consultation and operative notes were reviewed. 28% of patients were dissatisfied with surgery. Mean age =52.3±13.4 years with equal gender distribution. 87% were operated arthroscopically. 67% were in physically demanding occupations. There was a significant increase in OSS and QuickDASH at weeks 26 and 52 post-operatively (p<0.05), similar improvement was not noted in VAS pain score. Pain followed by stiffness were the main contributors of dissatisfaction. Multiple implicating factors were noted, the most common being acromio-clavicular joint arthritis (25.7%), suggesting concomitant pathologies as an additional cause for patient dissatisfaction. This is the first study to evaluate reasons for dissatisfaction following SAD. We noted high rates (28%) of dissatisfaction and a predilection for those involved in physically demanding occupations. We recommend meticulous pre-operative workup to identify co-existing pathologies and appropriate pre-operative counselling to improve outcomes in selected patients needing SAD following failure of conservative management

Mechanical ankle instability is elicited through examination and imaging. A subset of patients however report “functional” instability ie/ instability without objective radiological evidence. Little research compares operative outcomes between these groups. We hypothesised patients with “mechanical instability” were more likely to benefit from operative intervention than those with “functional instability”. This was a single centre, retrospective case note review of prospectively collected data. Inclusion criteria: over six months of symptoms, failed conservative management, surgical stabilisation between 2016–2018. Data collected: demographics, operative procedure, preoperative and postoperative PROMs. Nineteen patients were included. All had preoperative MRIs determining ligamentous involvement. Nine had radiological evidence of instability, eight had negative radiographs. Two were excluded due to no intraoperative radiographs. There was no statistical difference in preoperative MOxFQ scores between the groups (p=0.2039). Preoperative EQ5D-TTO scores were statistically different (mean mechanical 0.58 vs functional 0.26, p=0.0162) but not EQ5D-VAS scores (mean mechanical 77 vs functional 53, p=0.0806). Mechanical group's preoperative, 26 and 52 week scores respectively: Mean MOxFQ= 57.88, 22.13, 18.5. Mean EQ5D-TTO= 0.58, 0.78, 0.84. EQ5D-VAS= 77, 82, 82.5. Functional group's preoperative, 26 and 52 week scores respectively: Mean MOxFQ= 71.87, 37.75, 23. Mean EQ5D-TTO 0.26, 0.63, 0.76. EQ5D-VAS 53, 80, 88. This trend of improvement in PROMs was not reflected in patient satisfaction scores. 75% of respondents in the functional group reported dissatisfaction at 26 weeks versus no dissatisfaction in the mechanical group. We should consider counselling patients accordingly when offering surgery

The best method of managing a fracture of the distal humerus in a frail low-demand patient with osteoporotic bone remains controversial. Total elbow arthroplasty (TEA) has been recommended for patients in whom open reduction and internal fixation (ORIF) is not possible. Conservative methods of treatment, including the ‘bag of bones’ technique (acceptance of displacement of the bony fragments and early mobilisation), are now rarely considered as they are believed to give a poor functional result. We reviewed 40 elderly and low-demand patients (aged 50 to 93 years, 72% women) with a fracture of the distal humerus who had been treated conservatively at our hospital between March 2008 and December 2013, and assessed their short- and medium-term functional outcome. . In the short-term, the mean Broberg and Morrey score improved from 42 points (poor; 23 to 80) at six weeks after injury to 67 points (fair; 40 to 88) by three months. . In the medium-term, surviving patients (n = 20) had a mean Oxford elbow score of 30 points (7 to 48) at four years and a mean Disabilities of the Arm, Shoulder and Hand score of 38 points (0 to 75): 95% reported a functional range of elbow flexion. The cumulative rate of fracture union at one year was 53%. The mortality at five years approached 40%. . Conservative management of a fracture of the distal humerus in a low-demand patient only gives a modest functional result, but avoids the substantial surgical risks associated with primary ORIF or TEA. Cite this article: Bone Joint J 2015;97-B:1132–8

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

Aims

Distal third clavicle (DTC) fractures are increasing in incidence. Due to their instability and nonunion risk, they prove difficult to treat. Several different operative options for DTC fixation are reported but current evidence suggests variability in operative fixation. Given the lack of consensus, our objective was to determine the current epidemiological trends in DTC as well as their management within the UK.

Aims. The best method of treating unstable pelvic fractures that involve the obturator ring is still a matter for debate. This study compared three methods of treatment: nonoperative, isolated posterior fixation and combined anteroposterior stabilization. Patients and Methods. The study used data from the German Pelvic Trauma Registry and compared patients undergoing conservative management (n = 2394), surgical treatment (n = 1345) and transpubic surgery, including posterior stabilization (n = 730) with isolated posterior osteosynthesis (n = 405) in non-complex Type B and C fractures that only involved the obturator ring anteriorly. Calculated odds ratios were adjusted for potential confounders. Outcome criteria were intraoperative and general short-term complications, the incidence of nerve injuries, and mortality. Results. Operative stabilization reduced mortality by 36% (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.42 to 0.98) but the incidence of complications was twice as high (OR 2.04, 95% CI 1.57 to 2.64). Mortality and the incidence of neurological deficits at discharge were no different after isolated posterior or combined anteroposterior fixation. However, the odds of both surgical (98%, OR 1.98, 95%CI 1.22 to 3.22) and general complications (43%, OR 1.43, 95% CI 1.02 to 2.00) were higher in the group with the more extensive surgery. Conclusion. Operative stabilization is recommended for non-complex unstable pelvic fractures. The need for anterior fixation of obturator ring fractures should, however, be considered critically. Cite this article: Bone Joint J 2018;100-B:973–83

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.

The best surgical treatment of lateral epicondylitis remains uncertain. Recently radiofrequency microtenotomy (RFMT) has been proposed as a suitable surgical treatment. We aim to compare open release with RFMT and present the results of our randomised controlled trial. Patients with symptoms of tennis elbow for at least 6 months who had failed to respond to conservative management were included in the trial. They were randomised to open release or RFMT. Outcome measures included grip strength, pain and DASH scores. 41 patients were randomised, 23 to RFMT and 18 to open release, 2 patients withdrew from the study. Our results show that both treatments give a significant benefit at all time points for DASH and pain scores, but only open release gives a significant improvement in grip strength. Comparing the two treatments the only significant difference is the open group have better pain scores at 6 weeks, but this is not seen at later follow up. In conclusion both groups have shown benefit from the treatments, but one is not shown to be clearly superior

Introduction. Closed avulsion of the Flexor Digitorum Profundus (FDP) from distal phalanx most commonly affects the ring finger when an extensive force is applied to a finger in active flexion. Whilst it is undoubtably reasonable to provide treatment for those who present with symptoms, there may be a cohort of people who sustain an avulsion without noticing. This study aims to quantify the effect of ring finger FDP avulsion on overall grip strength to determine the functional effect of a missed injury. Method. Right handed volunteers, with no abnormality on examination were included (N= 42). Proximal muscle group action was excluded. Grip strength was tested using a Jamar dynamometer with and without splinting of the ring finger to block flexion at the DIPJ and repeated six times alternately to mitigate the effects of fatigue. Results. Most subjects showed a small (0.3–3kg) change in their average grip strength with the splint (N= 29). Some showed a dramatic change in their grip strength (6–11.4) (N=6) others showed no change or slight improvement with the splint (−3–0) (N=7). Data were not normally distributed (kolmogorov-smirnov p=0.023). A wilcoxon signed rank test showed a statistically significant difference in performance with, compared to without, the splint, mean 2.34kg reduction (−3.3 − 11.4) (p <0.0005. Discussion. Horton et al have examined the quadriga effect and shown that the individual strength of other digits is reduced when one FDP is isolated. This implies overall grip strength should be reduced; our data supports this assertion. However despite splinting, the majority of subjects were still within the normal range of power for age. Larger scale studies are required to assess the functional effect of repair vs conservative management

Aims

There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures.

Achilles tendinopathy is characterised by chronic degeneration of the Achilles tendon, usually secondary to injury or overuse. Extracorporeal shockwave treatment (ESWT) is of potential benefit in refractory cases where conservative management with analgesia, physiotherapy and corticosteroid injection have been unsuccessful. Patients with refractory Achilles tendinopathy enrolled between October 2010 and October 2011 received three sessions of ESWT over three weeks. Patients completed visual analogue scale (VAS) scores for pain at rest and on activity and the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire pre-treatment. These outcome measures and a six-point Likert satisfaction scale were reassessed at six and 16 weeks post treatment. 51 patients completed follow up. Mean age was 56 (34–80) years and mean length of symptoms 34 (4–252) months. Significant improvement (p<0.05) in VAS scores (rest and activity) and VISA-A scores was observed between baseline and 16 weeks. Mean Likert score was 3 (somewhat improved) at 16 weeks. Patients suffering Achilles tendinopathy for longer than 25 months had significantly less improvement than those affected for a shorter period. This study suggests that ESWT improves subjective and objective outcomes in patients with refractory Achilles tendinopathy

AIM. Chronic osteomyelitis still remains challenging and expensive to treat inspite of advances in antibiotics and operative techniques. We present our experience with free muscle flap after radical debridement of chronic osteomyelitis, performed as a single stage procedure. METHODS. We retrospectively identified eight patients (5 Females) with mean age of 63 yrs (Range40–71 yrs) Case notes were reviewed for co morbidities, Pre and post treatment inflammatory markers (plasma viscosity and CRP) and clinical staging. Mean follow up was 3 yrs (Range 1–6 yrs) All the patients were jointly operated by orthopaedic and plastic surgeons and underwent thorough debridement and muscle flap (Seven free flaps and one rotational flap) in the same sitting. All the patients were reviewed regularly by plastic and orthopaedic surgeons. Seven patients had free Gracilis flap and one had Triceps flap. Clinical assessment of reinfection was made on presence of erythema, wound discharge, pain and swelling. Primary outcome measure was resolution of infection. RESULTS. Seven patients had full resolution of osteomyelitis as evident by clinical examination and inflammatory markers. Three patients had graft problems to start with, but theses settled within six months One patient had minor wound discharge at three years which settled with conservative management. One further patient developed eczematous dermatitis around the flap which was managed successfully by the dermatologist. CONCLUSIONS. We believe this to be the only study in which both the procedures (debridement and muscle flap) are performed in one sitting. This technique is a successful and useful addition to the armamentarium of surgeons in the management of chronic osteomyelitis. Though our study is small but our results are encouraging

Aims

The aims of this network meta-analysis (NMA) were to examine nonunion rates and functional outcomes following various operative and nonoperative treatments for displaced mid-shaft clavicle fractures.

Aims

The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of ‘off-ended’ fractures in children with at least two years of potential growth remaining.