Aims. To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment. Methods. Patients were recruited from seven UK NHS centres and randomized to a three-arm pilot trial if aged older than 60 years and had a displaced acetabular fracture. Feasibility outcomes included patients’ willingness to participate, clinicians’ capability to recruit, and dropout rates. The primary clinical outcome measure was the EuroQol five-dimension questionnaire (EQ-5D) at six months. Secondary outcomes were Oxford Hip Score, Disability Rating Index, blood loss, and radiological and mobility assessments. Results. Between December 2017 and December 2019, 60 patients were recruited (median age 77.4 years, range 63.3 to 88.5) (39/21 M/F ratio). At final nine-month follow-up, 4/60 (7%) had withdrawn, 4/60 (7%) had died, and one had been lost to follow-up; a 98% response rate (50/51) was achieved for the EQ-5D questionnaire. Four deaths were recorded during the three-year trial period: three in the non-surgical treatment group and one in the fix-and-replace group. Conclusion. This study has shown a full-scale RCT to be feasible, but will need international recruitment. The Acetabular Fractures in older patients Intervention Trial (AceFIT) has informed the design of a multinational RCT sample size of 1,474 or 1,974 patients for a minimal clinically important difference of 0.06 on EQ-5D, with a power of 0.8 or 0.9, and loss to follow-up of 20%. This observed patient cohort comprises a medically complex group requiring multidisciplinary care; surgeon, anaesthetist, and ortho-geriatrician input is needed to optimize recovery and rehabilitation. Cite this article: Bone Joint J 2024;106-B(4):401–411

Aims. Following cast removal for nonoperatively treated distal radius fractures, rehabilitation facilitated by advice leaflet and advice video were compared to a course of face-to-face therapy. Methods. Adults with an isolated, nonoperatively treated distal radius fracture were included at six weeks post-cast removal. Participants were randomized to delivery of rehabilitation interventions in one of three ways: an advice leaflet; an advice video; or face-to-face therapy session(s). The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at six weeks post intervention and secondary outcome measures included DASH at one year, DASH work subscale, grip strength, and range of motion at six weeks and one year. Results. A total of 116 (97%) of 120 enrolled participants commenced treatment. Of those, 21 were lost to follow-up, resulting in 30 participants in the advice leaflet, 32 in the advice video, and 33 face-to-face therapy arms, respectively at six weeks of follow-up. There was no significant difference between the treatment groups in the DASH at six weeks (advice leaflet vs face-to-face therapy, p = 0.69; advice video vs face-to-face therapy, p = 0.56; advice leaflet vs advice video, p = 0.37; advice leaflet vs advice video vs face-to-face therapy, p = 0.63). At six weeks, there were no differences in any secondary outcome measures except for the DASH work subscale, where face-to-face therapy conferred benefit over advice leaflet (p = 0.01). Conclusion. Following cast removal for nonoperatively treated distal radius fractures, offering an advice leaflet or advice video for rehabilitation gives equivalent patient-reported outcomes to a course of face-to-face therapy. Cite this article: Bone Joint J 2021;103-B(6):1033–1039

This study aimed to assess the outcomes of patients with complex rib fractures undergoing operative or non-operative management at our center over a six-year time period.

Retrospective analysis was performed to identify all patients with complex rib fractures at our center from May 2016 to September 2022. Outcome measures included mechanical ventilation, tracheostomy, pneumonia, and mortality at one year.

388 patients with complex rib fractures were identified. 37 (10%) patients fulfilled criteria for surgical management and underwent rib fracture fixation; 351 patients were managed non-operatively with anaesthetic block or analgesia alone. The fixation group had a significantly higher proportion of patients with flail chest (30 (81%) vs 94 (27%), p<0.001) and were significantly more likely to require ICU admission (30 (81%) vs. 16 (5%), p<0.001) than the non-operative group. At one year follow-up, no significant differences were seen for mortality between these groups (1 (3%) vs. 27 (7%), p=0.276).

Of the surgical management group, those that underwent fixation <72 hours post injury were significantly less likely to develop pneumonia than those who were delayed >72 hours (2 (18%) vs 15 (58%), p=0.038), with downward trends noted for ICU length of stay (6 vs 10 days, p=0.140) and duration of mechanical ventilation (5 vs 8 days, p=0.177); no significant differences were seen for tracheostomy (3 vs. 5, p=0.588) or mortality (0 vs 1, p=0.856).

Surgical fixation of complex rib fractures improves outcomes in selected patient groups. Early surgical fixation led to reduced rates of pneumonia and may improve other outcome measures.

Septic Arthritis is an important life threatening condition affecting all age groups with a mortality of up to 11%. Our aim was to perform a study of the demographics, length of stay, complications and investigate if time delay of surgical treatment from the time of diagnosis has an impact on mortality and morbidity of the patients. Methods. We performed a retrospective study of all the patients presented to our Hospital between 2005 and 2009 with septic arthritis who underwent arthroscopic lavage as definitive intervention. We excluded the patients involving minor joints. Data collection was performed from case notes, microbiology and haematology laboratory results. We divided the patients into three groups based on the time from diagnosis to arthroscopic lavage as T1 (less than 12 hours), T2 (12–24 hours) and T3 (more than 24 hours). Our primary outcome measures were mortality and complications such as Intensive Care Admission. Secondary outcome measures included average length of stay in each group. Results. A total of 57 patients were evaluated. The average age of the patients was 49.7 (10 months–94 years). 2 patients of T1 group died (5.4%) 3 patients of T1 group needed Intensive Care Unit (ICU) management (8.1%). There were no deaths or ICU admissions in the other groups. 40.3% of patients needed arthroscopic lavage more than once. The average length of stay of T1 was 19.8 days, T2–11.5 days and T3–27.5 days. Majority of the joints involved were knees (63.1%).23 patients (40.3%) had a preceding intervention performed in the same joint. Staphyloccus aureus was the most common organism isolated in 14 patients (26.3%). Conclusion. There was insufficient evidence to show a significant correlation between the time lag and mortality associated with septic arthritis. However, further large scale retrospective multicenter based studies would be beneficial in identifying the factors associated with complications of septic arthritis. Our study demonstrates high morbidity and mortality rates in T1 group which may be biased due to highly unstable patients in this group in comparision to the other two groups

Heterotopic ossification (HO) of the hip after injury to the central nervous system can lead to joint ankylosis. Surgery is usually delayed to avoid recurrence, even if the functional status is affected. We report a consecutive series of patients with HO of the hip after injury to the central nervous system who required surgery in a single, specialised tertiary referral unit. As was usual practice, they all underwent CT to determine the location of the HO and to evaluate the density of the femoral head and articular surface. The outcome of surgery was correlated with the pre-, peri- and post-operative findings. In all, 183 hips (143 patients) were included of which 70 were ankylosed. A total of 25 peri-operative fractures of the femoral neck occurred, all of which arose in patients with ankylosed hips and were associated with intra-articular lesions in 18 and severe osteopenia of the femoral head in seven. All the intra-articular lesions were predicted by CT and strongly associated with post-operative complications. The loss of the range of movement before ankylosis is a more important factor than the maturity of the HO in deciding the timing of surgery. Early surgical intervention minimises the development of intra-articular pathology, osteoporosis and the resultant complications without increasing the risk of recurrence of HO

This project determines the numbers of UK service personnel with sports related injuries requiring physiotherapy or admission to Bastion Role 3 facility. We identified the trend of the injuries and how they were sustained during. The outcomes were recorded to determine the cost to the mission. Data was collected from April to September 2013. Results included 123 (29% of the deployed contingent in BSN catchment) were unfit for role whilst receiving treatment and 27 personnel (6%) were unable to return to their role in theatre due to their injury. 19 personnel were evacuated to UK, 7 to RCDM and 12 DAH to RRU. The mean length of hospital stay was 2.5 days, the total number of overnight stays was 58. The cost of an overnight stay in a Role 3 hospital bed is £200 and the cost of an escorted Aeromed £8,020. Incidence of sports injuries of UK personnel during H18, requiring role 1 or role 3 interventions was 6.3%. Individual PT accounted for 84% of injuries and 16% due to duty PT. 50% were lower limb injuries (UL – 25%, spine – 25%). Following treatment 94% patients remained in BSN in role, 4% Aeromed to UK. The potential cost was estimated at a minimum of £163,980

In a recent publication, 4.6% of 6450 Coalition deaths over ten years were reported to be due to junctional bleeding. The authors suggested that some of these deaths could have been avoided with a junctional hemorrhage control device.

Prospectively collected data on all injuries sustained in Afghanistan by UK military personnel over a 2 year period were reviewed. All fatalities with significant pelvic injuries were identified and analysed, and the cause of death established.

Significant upper thigh, groin or pelvic injuries were recorded in 124 casualties, of which 92 died. Pelvic injury was the cause of death in 42; only 1 casualty was identified where death was at least in part due to a vascular injury below the inguinal ligament, not controlled by a tourniquet, representing <1% of all deaths. Twenty one deaths were due to vascular injury between the aortic bifurcation and the inguinal ligament, of which 4 survived to a medical facility.

Some potentially survivable deaths due to exsanguination may be amenable to more proximal vascular control. We cannot substantiate previous conclusions that this can be achieved through use of a groin junctional tourniquet. There may be a role for more proximal vascular control of pelvic bleeding.

The aim of this study was to document the outcome following either early or delayed fixation for complex (AO-OTA type 43.C) fractures of the tibial plafond. From our trauma database we identified all patients who sustained a complex intra-articular fracture of the distal tibia over an 11-year period. Demographic data, fracture classification, management, complications and subsequent surgeries were recorded. The primary outcome measure was the development of early complications following surgery. The secondary outcome measure was the long-term patient reported outcome.

There were 102 type C pilon fractures in 99 patients with a mean age of 42yrs (16–86) and 75.5% (n=77) were male. 73 (71.6%) patients underwent primary open reduction internal fixation (ORIF), with 20 (19.6%) undergoing primary external fixation with delayed ORIF. 34 complications were recorded in 28 (27.5%) patients. There were 18 (17.6%) infections, with a deep wound infection in 9 (8.8%) patients and a superficial wound infection in 9 (8.8%). Risk factors for developing infection were multiple co-morbidities (p=0.008), an open fracture (p=0.008), and primary external fixation with delayed ORIF (p=0.023). At a mean of 6 years (0.3–13; n=53) post injury the mean FAOS score was 76.2 (0–100), the mean FADI score was 75.7 (0–100), and 72% (n=38) of patients were satisfied.

This is the largest series in the literature documenting the outcome following fixation for type C tibial pilon fractures. Despite the severity of these injuries, we have demonstrated a satisfactory outcome using primary early fixation in the vast majority of cases.

We present (with intra-operative imaging) 4 patients who sustained Pectoralis major ruptures on the same piece of equipment of the “Tarzan” assault course at the Commando Training Centre, Royal Marines (CTCRM). Recruits jump at running pace, carrying 21 pounds of equipment and a weapon (8 pounds) across a 6ft gap onto a vertical cargo-net. The recruits punch horizontally through the net, before adducting their arm to catch themselves, and all weight, on their axilla.

All patients presented with immediate pain and reduced function. 2 had ruptures demonstrated on MRI, 1 on USS and one via clinical examination. All 4 patients were found, at operation, to have sustained type IIIE injuries.

All patients underwent Pectoralis major repair using a uni-cortical button fixation and had an uneventful immediate post operative course. Patient 1 left Royal Marines training after the injury (out of choice, not because of failure to rehabilitate). All other patients are under active rehabilitation hoping to return to training.

Review of 10 years of records at CTCRM reveal no documented Pectoralis major rupture prior to our first case in October 2013. There has been no change to the obstacle or technique used and all patients deny the use of steroids.

Aims. Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures. Methods. We identified all periprosthetic fractures around a hip or knee arthroplasty from our prospectively collated database between 2012 and 2021. Patients were categorized into early or delayed intervention based on time from admission to surgery (early = ≤ 36 hours, delayed > 36 hours). Patient demographics, existing implants, Unified Classification System fracture subtype, acute medical issues on admission, preoperative haemoglobin, blood transfusion requirement, and length of hospital stay were identified for all patients. Complication and mortality rates were compared between groups. Results. A total of 365 patients were identified: 140 in the early and 225 in the delayed intervention group. Mortality rate was 4.1% at 30 days and 19.2% at one year. There was some indication that those who had surgery within 36 hours had a higher mortality rate, but this did not reach statistical significance at 30 days (p = 0.078) or one year (p = 0.051). Univariate analysis demonstrated that age, preoperative haemoglobin, acute medical issue on admission, and the presence of postoperative complications influenced 30-day and one-year mortality. Using a multivariate model, age and preoperative haemoglobin were independently predictive factors for one-year mortality (odds ratio (OR) 1.071; p < 0.001 and OR 0.980; p = 0.020). There was no association between timing of surgery and postoperative complications. Postoperative complications were more likely with increasing age (OR 1.032; p = 0.001) and revision arthroplasty compared to internal fixation (OR 0.481; p = 0.001). Conclusion. While early intervention may be preferable to reduce prolonged immobilization, there is no evidence that delaying surgery beyond 36 hours increases mortality or complications in patients with a femoral periprosthetic fracture. Cite this article: Bone Jt Open 2024;5(6):452–456

Aims. To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture. Methods. This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty). Results. Eight female (29%) and 20 male trainees (71%), mean age 29.4 years, performed 317 DHS operations and 243 hemiarthroplasties during ten months of follow-up. Primary analysis was a random effect model with surgeon-level fixed effects of patient condition, patient age, and surgeon experience, with a random intercept for surgeon. Under the intention-to-treat principle, for hemiarthroplasty there was better implant position in favour of cadaveric training, measured by leg length discrepancy ≤ 10 mm (odds ratio (OR) 4.08 (95% confidence interval (CI) 1.17 to 14.22); p = 0.027). There were significantly fewer postoperative blood transfusions required in patients undergoing hemiarthroplasty by cadaveric-trained compared to standard-trained surgeons (OR 6.00 (95% CI 1.83 to 19.69); p = 0.003). For DHS, there was no significant between-group difference in implant position as measured by tip-apex distance ≤ 25 mm (OR 6.47 (95% CI 0.97 to 43.05); p = 0.053). No between-group differences were observed for any secondary clinical outcomes. Conclusion. Trainees randomized to additional cadaveric training performed hip fracture fixation with better implant positioning and fewer postoperative blood transfusions in hemiarthroplasty. This effect, which was previously unknown, may be a consequence of the intervention. Further study is required. Cite this article: Bone Jt Open 2023;4(8):602–611

The aim was to predict the number and incidence of distal radius fractures in Scotland over the next two decades according to age group, categorised into under 65yrs(65) and 65yrs and older (65), and estimate the potential increased operative burden. The number of distal radius fractures in Scotland was isolated from the Global Burden of Disease database and this was used, in addition to historic population data and published population estimates, to create a multivariable model allowing incorporation of age group, sex and time. A Negative Binomial distribution was used to predict incidence in 2030 and 2040 and calculate projected number of fractures. A 20.4% operative intervention rate was assumed (local data). In terms of number of fractures, there was a projected 61% rise in the 65 group with an overall increase of 2099 fractures per year from 3417 in 2020 (95% confidence interval (CI) 2960 – 3463) to 5516 in 2040 (95% CI 4155 – 5675). This was associated with 428 additional operative interventions per year for those 65yrs. The projected increase between 2020 and 2040 was similar in both sexes (60% in females, 63% in males), however the absolute increase in fracture number was higher in females. There was a 4% projected fall in the number of fractures in those 65. Incidence of distal radius fractures is expected to considerably increase over the next two decades due to a projected increase in the number of fractures in the elderly. This has implications for associated morbidity and healthcare resource use

Introduction. The Tour de France, commonly recognised and the hardest physical endurance event on the planet, is an iconic cycling competition with a history of ever impressive performances and increasingly notable injuries. This study aims to methodologically catalogue and analyse injuries sustained by professional riders over a span of six years and understand the operative workload created by this prestigious race. (2018–2023). Methods. Data was gathered from multiple publicly available sources, including pro-cycling stats, news articles, team press releases and independent medical reports. Each injury was categorized by year, rider, and injury type. Results. From 2018–2023, there was a significant diversity in both injured body part and mechanism of injury. Of the 124 recorded race ending incidents clavicle fractures accounted 19.4%, laceration/contusions 12.1%, patella fractures 10.5% and elbow fractures 7.3%. Other. notable other body areas undergoing surgical intervention were hand fractures 5.6%, pelvic fractures 2.4% and femoral fracture 1.6%. At a mean of 20.67 injuries per tour, this accounts for almost exactly one race ending injury per day where an athlete finishes the day on the operating table, rather than the team bus. Discussion. The Tour de France's rigorous challenges are mirrored in its injury statistics. Over six years, clavicle fractures were most prevalent, likely due to cyclists' instinct to brace during crashes. Lacerations, contusions, and patella fractures also featured prominently. Alarmingly, each race stage averaged an injury severe enough for surgical intervention. This data highlights the imperative need for enhanced protective measures, race regulations, and medical preparedness to protect these elite athletes

The Trauma Triage clinic (TTC) is a Virtual Fracture clinic which permits the direct discharge of simple, isolated fractures from the Emergency Department (ED), with consultant review of the clinical notes and radiographs. This study details the outcomes of patients with such injuries over a four-year period. All TTC records between January 2014 and December 2017 were collated from a prospective database. Fractures of the radial head, little finger metacarpal, fifth metatarsal, toe phalanges and soft tissue mallet finger injuries were included. Application of the direct discharge protocol, and any deviations were noted. All records were then re-assessed at a minimum of three years after TTC triage (mean 4.5 years) to ascertain which injuries re-attended the trauma clinic, reasons for re-attendance, source of referral and any subsequent surgical procedures. 6709 patients with fractures of the radial head (1882), little finger metacarpal (1621), fifth metatarsal (1916), toe phalanges (920) and soft tissue mallet finger injures (370) were identified. 963 (14%) patients were offered in-person review after TTC, of which 45 (0.6%) underwent a surgical intervention. 299 (4%) re-attended after TTC direct discharge at a mean time after injury of 11.9 weeks and 12 (0.2%) underwent surgical intervention. Serious interventions, defined as those in which a surgical procedure may have been avoided if the patient had not undergone direct discharge, occurred in 1 patient (0.01%). Re-intervention after direct discharge of simple injuries of the elbow, hand and foot is low. Unnecessary deviations from protocol offer avenues to optimise consumption of service resources

Aims. Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance. Methods. We undertook a preliminary, pragmatic, single-blinded, multicentre, randomized controlled trial of cadaveric simulation versus standard training. Primary outcome was fracture reduction on postoperative radiographs. Results. Overall, 139 ankle fractures were fixed by 28 postgraduate year three to five trainee surgeons (mean age 29.4 years; 71% males) during ten months' follow-up. Under the intention-to-treat principle, a technically superior fixation was performed by the cadaveric-trained group compared to the standard-trained group, as measured on the first postoperative radiograph against predefined acceptability thresholds. The cadaveric-trained group used a lower intraoperative dose of radiation than the standard-trained group (mean difference 0.011 Gym. 2. , 95% confidence interval 0.003 to 0.019; p = 0.009). There was no difference in procedure time. Conclusion. Trainees randomized to cadaveric training performed better ankle fracture fixations and irradiated patients less during surgery compared to standard-trained trainees. This effect, which was previously unknown, is likely to be a consequence of the intervention. Further study is required. Cite this article: Bone Jt Open 2023;4(8):594–601

Aims. To report the outcomes of patients with a fracture of the distal tibia who were treated with intramedullary nail versus locking plate in the five years after participating in the Fixation of Distal Tibia fracture (FixDT) trial. Methods. The FixDT trial reported the results for 321 patients randomized to nail or locking plate fixation in the first 12 months after their injury. In this follow-up study, we report the results of 170 of the original participants who agreed to be followed up until five years. Participants reported their Disability Rating Index (DRI) and health-related quality of life (EuroQol five-dimension three-level questionnaire) annually by self-reported questionnaire. Further surgical interventions related to the fracture were also recorded. Results. There was no evidence of a difference in patient-reported disability, health-related quality of life, or the need for further surgery between participants treated with either type of fixation at five years. Considering the combined results for all participants, there was no significant change in DRI scores after the first 12 months of follow-up (difference between 12 and 24 months, 3.3 (95% confidence interval -1.8 to 8.5); p = 0.203), with patients reporting around 20% disability at five years. Conclusion. This study shows that the moderate levels of disability and reduced quality of life reported by participants 12 months after a fracture of the distal tibia persist in the medium term, with little evidence of improvement after the first year. Cite this article: Bone Joint J 2023;105-B(7):795–800

Aims. The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes. Methods. Between May 2012 and December 2020, 203 patients with infected segmental bone defects treated with the IMT were enrolled. The digital medical records of these patients were retrospectively analyzed. Factors associated with unfavourable outcomes were identified through logistic regression analysis. Results. Among the 203 enrolled patients, infection recurred in 27 patients (13.3%) after bone grafting. The union rate was 75.9% (154 patients) after second-stage surgery without additional procedures, and final union was achieved in 173 patients (85.2%) after second-stage surgery with or without additional procedures. The mean healing time was 9.3 months (3 to 37). Multivariate logistic regression analysis of 203 patients showed that the number (≥ two) of debridements (first stage) was an independent risk factor for infection recurrence and nonunion. Larger defect sizes were associated with higher odds of nonunion. After excluding 27 patients with infection recurrence, multivariate analysis of the remaining 176 patients suggested that intramedullary nail plus plate internal fixation, smoking, and an allograft-to-autograft ratio exceeding 1:3 adversely affected healing time. Conclusion. The IMT is an effective method to achieve infection eradication and union in the management of infected segmental bone defects. Our study identified several risk factors associated with unfavourable outcomes. Some of these factors are modifiable, and the risk of adverse outcomes can be reduced by adopting targeted interventions or strategies. Surgeons can fully inform patients with non-modifiable risk factors preoperatively, and may even use other methods for bone defect reconstruction. Cite this article: Bone Joint J 2024;106-B(6):613–622

Aims. To determine whether platelet-rich plasma (PRP) injection improves outcomes two years after acute Achilles tendon rupture. Methods. A randomized multicentre two-arm parallel-group, participant- and assessor-blinded superiority trial was undertaken. Recruitment commenced on 28 July 2015 and two-year follow-up was completed in 21 October 2019. Participants were 230 adults aged 18 years and over, with acute Achilles tendon rupture managed with non-surgical treatment from 19 UK hospitals. Exclusions were insertion or musculotendinous junction injuries, major leg injury or deformity, diabetes, platelet or haematological disorder, medication with systemic corticosteroids, anticoagulation therapy treatment, and other contraindicating conditions. Participants were randomized via a central online system 1:1 to PRP or placebo injection. The main outcome measure was Achilles Tendon Rupture Score (ATRS) at two years via postal questionnaire. Other outcomes were pain, recovery goal attainment, and quality of life. Analysis was by intention-to-treat. Results. A total of 230 participants were randomized, 114 to PRP and 116 to placebo. Two-year questionnaires were sent to 216 participants who completed a six-month questionnaire. Overall, 182/216 participants (84%) completed the two-year questionnaire. Participants were aged a mean of 46 years (SD 13.0) and 25% were female (57/230). The majority of participants received the allocated intervention (219/229, 96%). Mean ATRS scores at two years were 82.2 (SD 18.3) in the PRP group (n = 85) and 83.8 (SD 16.0) in the placebo group (n = 92). There was no evidence of a difference in the ATRS at two years (adjusted mean difference -0.752, 95% confidence interval -5.523 to 4.020; p = 0.757) or in other secondary outcomes, and there were no re-ruptures between 24 weeks and two years. Conclusion. PRP injection did not improve patient-reported function or quality of life two years after acute Achilles tendon rupture compared with placebo. The evidence from this study indicates that PRP offers no patient benefit in the longer term for patients with acute Achilles tendon rupture. Cite this article: Bone Joint J 2022;104-B(11):1256–1265

Midfoot arthrodesis is the conventional surgical intervention for midfoot arthritis. Arthrodesis aims to stabilise, realign and fuse the affected joints, providing patients with improved pain and function. Current research neglects the measurement of patient reported outcomes. This study aimed to investigate objective, and patient reported outcomes of midfoot arthrodesis. The secondary aim was to identify variables predicting the development of non-union. An automated search of online patient records identified 108 eligible patients (117 feet). The rates of union, re-operations, and complications were calculated using radiographs and medical records. Logistic regression was used to model variables influencing the odds of non-union. All living patients were posted a Manchester Oxford Foot Questionnaire (MOx-FQ), a patient reported outcome assessment. Pre-operative MOx-FQ results were available in a minority of cases. Students t-test was used to compare pre- and post-operative MOx-FQ scores. The rate of union achieved was 74%. The rate of re-operations was 35%. The rate of complications was 14%. Bone grafts and staple fixation independently impacted the odds of non-union. Bone grafts decreased the odds of non-union, whilst staple fixation increased the odds. This finding agrees with the opinion of other researchers. We recommend the use of bone grafts, and the avoidance of fixation with staples. Previous attempts have been made to assess patient outcomes. However, this study is the first to use the MOx-FQ, a validated questionnaire. Therefore, this study establishes a baseline for improvements in patient reported outcomes

Myriad protocols exist for isolated Weber B lateral malleolus fractures with a congruent tibiotalar joint on initial radiographs. Stress and weight-bearing radiographs, all at various timepoints, may be employed to identify those injuries that develop significant talar shift but consensus is elusive. This study outlines a safe and reproducible protocol for such injuries, utilising a removable orthosis, immediate weight bearing and standard supine radiographs. A retrospective analysis of a prospective trauma database was analysed to identify patients with an isolated Weber B ankle fracture with adequate presentation radiographs demonstrating a congruent mortise. Patient records and radiographs were evaluated a minimum of 5 years after initial presentation to determine ankle stability, complications, and the burden on outpatient services. Between 2014 and 2016, 657 patients were referred to the specialist trauma clinic from the emergency department. Of the 657, 52 patients had inadequate ED radiographs to determine ankle congruity. At the two-week assessment, 11 of the 52 demonstrated talar shift and required intervention. Therefore 646 patients demonstrated ankle congruity at two weeks after weight bearing. No patient demonstrated talar shift at the six-week assessment. Average number of follow up appointments was 2.4 with 3.5 radiographs. Our new treatment protocol advocates discharge after a single orthopaedic assessment after two weeks of weight bearing. This study supports immediate weight-bearing of Weber B ankle fractures with a congruent mortise in an orthosis. Follow up beyond two weeks is unnecessary and our protocol offers a safe means of significantly reducing the outpatient burden