Metacarpal fractures represent up to 33% of all hand fractures; of which the majority can be treated non-operatively. Previous research has shown excellent putcomes with non-operative treatment yet surgical stabilisation is recommended to avoid malrotation and symptomatic shortening. It is unknown whether operative is superior to non-operative treatment in oblique or spiral metacarpal shaft fractures. The aim of the study was to compare non-operative treatment of mobilisation with open surgical stabilisation. 42 adults (≥ 18 years) with a single displaced oblique or spiral metacarpal shaft fractures were randomly assigned in a 1:1 pattern to either non-operative treatment with free mobilisation or operative treatment with open reduction and fixation with lag screws in a prospective study. The primary outcome measure was grip-strength in the injured hand in comparison to the uninjured hand at 1-year follow-up. The Disabilities of the Arm, Shoulder and Hand Score, ranges of motion, metacarpal shortening, complications, time off work, patient satisfaction and costs were secondary outcomes. All 42 patients attended final follow-up after 1 year. The mean grip strength in the non-operative group was 104% (range 73–250%) of the contralateral hand and 96% (range 58–121%) in the operatively treated patients. Mean metacarpal shortening was 5.0 (range 0–9) mm in the non-operative group and 0.6 (range 0–7) mm in the operative group. There were five minor complications and three revision operations, all in the operative group. The costs for non-operative treatment were estimated at 1,347 USD compared to 3,834USD for operative treatment; sick leave was significantly longer in the operative group (35 days, range 0–147) than in the non-operative group (12 days, range 0–62) (p=0.008). When treated with immediate free mobilization single, patients with displaced spiral or oblique metacarpal shaft fractures have outcomes that are comparable to those after operative treatment, despite some metacarpal shortening. Complication rates, costs and sick leave are higher with operative treatment. Early mobilisation of spiral or long oblique single metacarpal fractures is the preferred treatment. Trial registration number: ClinicalTrials.gov NCT03067454

Plantar fasciitis (PF) is one of the widespread conditions causing hindfoot pain. The most common presenting symptoms are functional limitation and pain (first step and activity) on plantar surface of the foot. The non-operative treatments provide complete resolution of pain in 90% of patients, but functional limitation still remains as a risk factor for recurrency of PF. Although the number of non-operative treatment options showing efficacy on pain and functional limitation are excessive, the evidences are limited for functional limitation. Additionally, Mulligan mobilization with movement (MMWM) in Chronic Plantar Fasciitis has been poorly studied in the literature. According to these findings, the study was aimed to determine effectiveness of Mulligan mobilization with movement on Chronic Plantar Fasciitis. A total of 25 patients (40 feet) with chronic PF were included in the study. The patients were randomly divided into Mulligan concept rehabilitation group (PF-M, n=20 feet) and Home Rehabilitation group (PF-H, n=20 feet). (MMWM), Foot and ankle exercises program were applied to PF-M, twice a week totally 8 week (16 sessions) and foot- ankle exercises as a home program were given for PF-H, 8 weeks. The range of motion (ROM) for dorsiflexion and plantar flexion was measured by using a manual goniometer. Pain, disability and activity restriction were assessed by Foot Function Index (FFI) . The first step morning pain was evaluated by Visual Analogue Scale (VAS) and Kinesiophobia was also reported by using Tampa Scale (TSK). Patients were evaluated at baseline and 8 weeks. FFI, VAS, TSK, ROM values improved in all groups (intragroup variability) at 8th week (P < .05). The other result indicated that ROM values for DF and PF and TSK scores in PF-M had more significant improvement than PF-H (p<.05). To the best of our knowledge this is the first randomised controlled trial for investigating Mulligan Concept efficiancy on chronic PF. Both Mulligan mobilization with movement (MMWM) and exercise protocols are effective for chronic PF. Furthermore, The Mulligan concept seems more effective treatment option in reducing kinesiophobia and improving functional capacity

Abstract. Objectives. The outcomes from patella fracture have remained dissatisfactory despite advances in treatment, especially from operative fixation1. Frequently, reoperation is required following open reduction and internal fixation (ORIF) of the patella due to prominent hardware since the standard technique for patella ORIF is tension band wiring (TBW) which inevitably leaves a bulky knot and irritates soft tissue given the patella's superficial position2. We performed a systematic review to determine the optimal treatment of patella fractures in the poor host. Methods. Three databases (EMBASE/Medline, ProQuest and PubMed) and one register (Cochrane CENTRAL) were searched. 476 records were identified and duplicates removed. 88 records progressed to abstract screening and 73 were excluded. Following review of complete references, 8 studies were deemed eligible. Results. Complication rates were shown to be high in our systematic review. Over one-fifth of patients require re-operation, predominantly for removal of symptomatic for failed hardware. Average infection rate was 11.95% which is higher than rates reported in the literature for better hosts. Nevertheless, reported mortality was low at 0.8% and thromboembolic events only occurred in 2% of patients. Average range of movement achieved following operative fixation was approximately 124 degrees. Upon further literature review, novel non-operative treatment options have shown acceptable results in low-demand patients, including abandoning weight-bearing restrictions altogether and non-operatively treating patients with fracture gaps greater than 1cm. Regarding operative management, suture/cable TBW has been investigated as a viable option with good results in recent years since the materials used show comparable biomechanics to stainless steel. Additionally, ORIF with locking plates have shown favourable results and have enabled aggressive post-operative rehabilitation protocols. TBW with metallic implants has shown higher complication rates, especially for anterior knee pain, reoperation and poor functional outcomes. Conclusion. There is sparse literature regarding patella fracture in the poor host. Nevertheless, it is clear that ORIF produces better outcomes than conservative treatment but the optimal technique for patella ORIF remains unclear. TBW with metallic implants should not remain the standard technique for ORIF; low-profile plates of suture TBW are more attractive solutions. Non-operative treatment may be considered for low-demand individuals however any form of patellectomy should be avoided if possible. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Knee osteoarthritis is a common, debilitating condition. Intra articular corticosteroid injections are a commonly used non-operative treatment strategy. Intra articular hip injection with Ketorolac (an NSAID) has proven to be as efficacious as corticosteroids. No prior study compares the efficacy of Ketorolac relative to corticosteroids for relief of discomfort in knee osteoarthritis. The study design was a single centre double blinded RCT. Severity of osteoarthritic changes were graded on plain film weightbearing radiographs using the Kellgren and Lawrence system. Injection was with either 30mg Ketorolac or 40mg Methylprednisolone, given by intra-articular injection, in a syringe with 5mls 0.5% Marcaine. Pre-injection clinical outcomes were assessed using the Numerical Pain Score (NPS), WOMAC, and Oxford knee scores. Patients' NPS scores were assessed at Day 1 and Day 14 post-injection. An assessment of all clinical outcomes took place in clinic at six weeks. There were 72 participants (83 knees) in the study. No patients were lost to follow-up. Mean age was 62.66 years (Range 29–85). 42 knees received a corticosteroid injection, 41 a NSAID injection. Mean Kellgren and Lawrence score was 3.1. There was no significant difference in pre-injection clinical scores in either group. There was a significant improvement of NPS on Day 1 and 14 in both injection groups(p<0.05). These improved pain scores were sustained at 6 weeks in both groups. WOMAC and Oxford Knee Scores showed a statistically significant improvement in the corticosteroid group. WOMAC scores showed significant improvement in the NSAID group, however these improvements didn't achieve statistical significance using the Oxford Knee Score. Corticosteroid or NSAID injectate are a safe and effective non-operative treatment strategy in the patient with knee osteoarthritis. Ketorolac appears to provide effective medium-term improvement of pain and clinical scores. Further follow-up is recommended to investigate if this trend in sustained

Background. Avulsion fractures of the base of the fifth metatarsal are some of the commonest foot injuries. The robust scientific evidence on the optimal non-operative treatment of these fractures is scant. We designed and conducted a prospective randomised non-inferiority controlled trial of symptomatic treatment versus cast immobilisation with the null hypothesis that cast immobilisation gave substantial benefit over the symptomatic treatment in terms of patient reported outcome measures(PROMs). The alternative hypothesis was that symptomatic treatment was not inferior. Methods. The primary outcome was the validated Visual Analogue Scale Foot and Ankle (VAS FA) score ranging from 0 to 100. The non-inferiority boundary was set at −10 points. Power sizing determined a minimum of 12 patients per group. Anticipating a significant loss to follow up, 60 patients of 16 years of age or older were randomised to receive either below knee walking cast immobilisation (n = 24) or symptomatic double- elasticated bandage (n = 36) for 4 weeks. Secondary outcome measures were EuroQol-5D, and American Orthopaedic Foot and Ankle Society scores. Data was analysed at the baseline, 4 weeks, 3 months and 6 months post injury by a clinician blinded to a treatment arm. Results. Symptomatic treatment proved to be non-inferior to cast immobilisation treatment in terms of VAS FA at baseline, 4 weeks and 6 months. Secondary outcomes showed similar comparative values between two treatment groups. Loss to follow up reached 43% at 6 months. The imputation of missing data was done and confirmed the non-inferiority of symptomatic treatment. Conclusions. Cast immobilisation does not appear to give benefits over symptomatic treatment of these injuries in terms of validated PROMs in adults. A significant loss to follow up should be expected with these fractures in medium term. Level of Evidence. II. Approval. NRES Yorkshire and the Humber reference: 11/YH/0297. Disclosure. This study was supported with a small research grant from a British Orthopaedic Foot and Ankle Society

Introduction. Osteonecrosis of the femoral head usually progresses to collapse in up to 70% to 80% of all cases. Previous studies have shown high failure rates with non-operative treatment, whereas, some surgical options including bone grafting, core decompression, osteotomy and arthroplasty have been recommended. Total hip arthroplasty and hemiarthroplasty, either cemented or cementless, are the last resort for improving the functional outcomes for the elderly. However, salvage of the femoral head in relatively young patients is widely advocated. Thus vascularized bone grafting has been recommended to salvage the collapsing femoral head. The purpose of this study was to evaluate the prognostic factors related to the outcome of the vascularized iliac bone grafting in the treatment of osteonecrosis of the femoral head. Methods. A retrospective case series review study is presented. Between April 1987 and April 2003, 47 patients (51 hips) in the authors' hospital underwent vascularized iliac bone grafting for the treatment of osteonecrosis of the femoral head. Three patients were lost to follow-up, thus, 44 patients (48 hips), 38 men and 4 women, were included in the study. All patients underwent operation by one experienced senior surgeon. Patients were grouped according to related risk factors, i.e., trauma, corticosteroid, alcohol, and an idiopathic group. A radiographic scale, the Ficat and Arlet classification system, was used for grading the osteonecrosis. We set the conversion to total hip arthroplasty as the end point for survival of vascularized iliac bone grafting in this study. Kaplan-Meier survivorship analysis was used to determine the significance with regard to the risk factors, age, Ficat and Arlet staging, gender, and side. Results. The Kaplan-Meier survivorship analysis showed that the 5-year overall rate of graft survival was 68.5% (95% confidence interval: 52.7% to 80.0%), 10-year overall rate of graft survival was 61.5% (95% confidence interval: 44.4% to 74.8%), and 61.5% (95% confidence interval: 44.4% to 74.8%) at 15 years. There was no significant difference between the groups regarding the prognostic factors of etiology, gender, side, and stage. The only significant parameter was the age that the patients older than 50 years had the worst 5-year survival rate of the femoral head (p<0.05). Conclusion. Vascularized bone grafting is a technically demanding procedure when compared to conventional core decompression or arthroplasty. However, this technique can preserve the femoral head from collapse and preclude the need for arthroplasty in young patients

Introduction. Subchondral insufficiency fracture of the femoral head (SIF) often occurs in osteoporotic elderly patients. Patients usually suffer from acute hip pain without any obvious antecedent trauma. Radiologically, a subchondral fracture is seen mainly in the superolateral portion of the femoral head. The T1-weighted magnetic resonance (MR) images show a low-intensity band in the subchondral area of the femoral head, which tends to be irregular, disconnected, and convex to the articular surface. This low-intensity band in SIF was histologically proven to correspond to the fracture line with associated repair tissue. Some cases of SIF resolve after conservative treatment, while others progress until collapse, thereby requiring surgical treatment. The prognosis of SIF remains unclear. This study investigated the risk factors that influence the prognosis of SIF based on the progression of the collapse. Methods. Between June 2002 and June 2008, seventeen patients diagnosed as SIF were included in this study. Sequential radiographs were evaluated for the presence of progression of the collapse. The clinical profiles, including the age, body mass index (BMI), follow-up period and Singh index were examined. The morphological characteristics of the low intensity band on the T1-weighted magnetic resonance images were also examined, with regard to the band length, band thickness and band length ratio; which is defined as a proportion of the band length to the weight-bearing portion of the femoral head. Results. Radiographically, a progression of the collapse was observed in 8 of 17 (47.1%) patients. The band length in patients with progression of the collapse (mean: 22.6 mm) was significantly larger than that in those without progression of the collapse (mean: 12.3 mm; P < 0.05). The band length ratio in patients with progression of the collapse (mean: 73.3 %) was also significantly higher than that in those without progression of the collapse (mean: 42.3 %; P < 0.01). No significant differences were seen in the other variables (the age, BMI, follow-up period, Singh index, and band thickness). Conclusion. One of the important differential diagnoses in determining SIF may include osteonecrosis. The shape of the low signal intensity band on the T1-weighted MR images is one of the characteristic findings in SIF: namely, it is generally irregular, serpiginous, convex to the articular surface, and often discontinuous. This low-intensity band is generally surrounded by bone marrow edema. Histopathologically the band in SIF represents the fracture line with associated repair tissue. On the other hand, in osteonecrosis, since the low-intensity band represents repair tissue, it is generally smooth and circumscribes all of the necrotic segments. In this study, the prognosis of SIF varied even though all the patients received similar non-operative treatments. If the prognosis for SIF can be predicted at the early stage, it would allow the design of optimal treatments in each patient. In this preliminary investigation, both the band length and band length ratio were demonstrated to be useful when selecting the optimal treatment for SIF

We performed a biomechanical study to compare the augmentation of isolated fractured vertebral bodies using two different bone tamps. Compression fractures were created in 21 vertebral bodies harvested from red deer after determining their initial strength and stiffness, which was then assessed after standardised bipedicular vertebral augmentation using a balloon or an expandable polymer bone tamp.

The median strength and stiffness of the balloon bone tamp group was 6.71 kN (sd 2.71) and 1.885 kN/mm (sd 0.340), respectively, versus 7.36 kN (sd 3.43) and 1.882 kN/mm (sd 0.868) in the polymer bone tamp group. The strength and stiffness tended to be greater in the polymer bone tamp group than in the balloon bone tamp group, but this difference was not statistically significant (strength p > 0.8, and stiffness p = 0.4).

We assessed the predictive value of the macroscopic and detailed microscopic appearance of the coracoacromial ligament, subacromial bursa and rotator-cuff tendon in 20 patients undergoing subacromial decompression for impingement in the absence of full-thickness tears of the rotator cuff. Histologically, all specimens had features of degenerative change and oedema in the extracellular matrix. Inflammatory cells were seen, but there was no evidence of chronic inflammation. However, the outcome was not related to cell counts.

At three months the mean Oxford shoulder score had improved from 29.2 (20 to 40) to 39.4 (28 to 48) (p < 0.0001) and at six months to 45.5 (36 to 48) (p < 0.0001). At six months, although all patients had improved, the seven patients with a hooked acromion had done so to a less extent than those with a flat or curved acromion judged by their mean Oxford shoulder scores of 43.5 and 46.5 respectively (p = 0.046). All five patients with partial-thickness tears were within this group and demonstrated less improvement than the patients with no tear (mean Oxford shoulder scores 43.2 and 46.4, respectively, p = 0.04). These findings imply that in the presence of a partial-thickness tear subacromial decompression may require additional specific treatment to the rotator cuff if the outcome is to be improved further.