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 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

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

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

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

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

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

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

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: 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

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

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

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

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

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

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

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

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

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

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