Background. Primary dislocation of the patella is a common acute knee disorder in children, adolescents and young adults. While primary dislocation of the patella has traditionally been treated non-operatively, primary operative repair of the medial patella-stabilizing soft tissues has been popularized more recently and thought to reduce the risk of dislocation. However, several studies have shown substantial rates of redislocation with longer follow-up time, irrespective of treatment. The purpose of this systematic review was to compare operative and
Limited long term data exists comparing operatively and non-operatively treated Achilles tendon ruptures. A previous randomised controlled trial comparing early outcomes showed a short term advantage for surgery, but there are no long term prospective randomised comparisons. Our aim was to determine whether surgery conferred long term benefits in terms of patient reported outcomes or re-rupture. 64 patients (80%) were followed up with postal questionnaires. Patients were asked to complete the Short Musculoskeletal Function Assessment (SMFA), Achilles Tendon Total Rupture Score (ATRS) and EQ-5D questionnaires, and to report re-ruptures. 32 patients were treated non-operatively and 32 operatively; 59 completed the SMFA and 64 the ATRS and EQ-5D assessments. There was no significant difference in SMFA score (median 1.09, IQR 4.89 in the cast group versus 2.17 and 7.07 in the operative group; p=0.347), ATRS (median 96, IQR 18 versus 93 and 15; p=0.509), EQ-5D Index (median 1.0, IQR 0.163 versus 1.0 and 0.257; p=0.327) and EQ-5D Visual Analogue Score (median score 85, IQR 15 versus 85 and 24; p=0.650). There were 2 re-ruptures in the operative group and 4 in the non-operative group (p=0.067). This is the first prospective, randomised, long term report comparing operative and non-operative management. At follow up between 13–17 years after injury, patients reported good function and health related quality of life. There was no significant difference in re-rupture rate between the treatment groups.
The PROximal Fracture of the Humerus Evaluation by Randomisation
(PROFHER) randomised clinical trial compared the operative and non-operative
treatment of adults with a displaced fracture of the proximal humerus
involving the surgical neck. The aim of this study was to determine
the long-term treatment effects beyond the two-year follow-up. Of the original 250 trial participants, 176 consented to extended
follow-up and were sent postal questionnaires at three, four and
five years after recruitment to the trial. The Oxford Shoulder Score
(OSS; the primary outcome), EuroQol 5D-3L (EQ-5D-3L), and any recent
shoulder operations and fracture data were collected. Statistical
and economic analyses, consistent with those of the main trial were
applied.Aims
Patients and Methods
This study aimed to evaluate the effect of clavicular shortening, measured by three-dimensional computerized tomography (3DCT), on functional outcomes and satisfaction in patients with healed, displaced, midshaft clavicle fractures up to one year following injury. The data used in this study were collected as part of a multicenter, prospective randomized control trial comparing open reduction and plate fixation with nonoperative treatment for displaced midshaft clavicle factures. Patients who were randomized to nonoperative treatment and who had healed by one year were included. Clavicle shortening relative to the uninjured contralateral clavicle was measured on 3DCT. Outcome analysis was conducted at six weeks, three months, six months and one year following injury and included the Disabilities of the Arm, Shoulder and Hand (DASH), Constant and Short Form-12 (SF-12) scores, and patient satisfaction. 48 patients were included. The mean shortening of injured clavicles, relative to the contralateral side, was 11mm (+/− 7.6mm) with a mean proportional shortening of 8percnt;. Proportional shortening did not significantly correlate with the DASH (p>0.42), Constant (p>0.32) or SF-12 (p>0.08) scores at any time point. There was no significant difference in the mean DASH or Constant scores at any followup time point both when the cut off for shortening was defined as one centimeter (p>0.11) or two centimeters (p>0.35). There was no significant difference in clavicle shortening between satisfied and unsatisfied patients (p>0.49). This study demonstrated no association between shortening and functional outcome or satisfaction in patients with healed, displaced, midshaft clavicle fractures up to one year following injury.
The generally-accepted treatment for large, displaced fractures of the glenoid associated with traumatic anterior dislocation of the shoulder is operative repair. In this study, 14 consecutive patients with large (>
5 mm), displaced (>
2 mm) anteroinferior glenoid rim fractures were treated non-operatively if post-reduction radiographs showed a centred glenohumeral joint. After a mean follow-up of 5.6 years (2.8 to 8.4), the mean Constant score and subjective shoulder value were 98% (90% to 100%) and 97% (90% to 100%), respectively. There were no redislocations or subluxations, and the apprehension test was negative. All fragments healed with an average intra-articular step of 3.0 mm (0.5 to 11). No patient had symptoms of osteoarthritis, which was mild in two shoulders and moderate in one. Traumatic anterior dislocation of the shoulder, associated with a large displaced glenoid rim fracture can be successfully treated non-operatively, providing the glenohumeral joint is concentrically reduced on the anteroposterior radiograph.
This prospective, randomized, controlled trial compares patient outcome after non-operative care versus open reduction and tunneled suspension device fixation (ORTSD) for grade III or IV acromioclavicular joint disruptions. Sixty patients aged between sixteen and thirty-five years with an acute grade III or IV AC joint disruption were randomized to receive ORTSD fixation or
Management of highly displaced acromioclavicular joint (ACJ) injuries remain contentious. It is unclear if delayed versus acute reconstruction has an increased risk of fixation failure and complications. The primary aim of this was to compare complications of early versus delayed reconstruction. The secondary aim was to determine modes of failure of ACJ reconstruction requiring revision surgery. A retrospective study was performed of all patients who underwent operative reconstruction of ACJ injuries over a 10-year period (Rockwood III-V). Reconstruction was classed as early (<12 weeks from injury) or delayed (≥12 weeks). Patient demographics, fixation method and post-operative complications were noted, with one-year follow-up a minimum requirement for inclusion. Fixation failure was defined as loss of reduction requiring revision surgery. 104 patients were analysed (n=60 early and n=44 delayed). Mean age was 42.0 (SD 11.2, 17–70 years), 84.6% male and 16/104 were smokers. No difference was observed between fixation failure (p=0.39) or deep infection (p=0.13) with regards to acute versus delayed reconstruction. No patient demographic or timing of surgery was predictive of fixation failure on regression modelling. Overall, eleven patients underwent revision surgery for loss of reduction and implant failure (n=5 suture fatigue, n=2 endo-button escape, n=2 coracoid stress fracture and n=2 deep infection). This study suggests that delayed ACJ reconstruction does not have a higher incidence of fixation failure or major complications compared to acute reconstruction. For those patients with ongoing pain and instability following a trial of
Fractures of the lateral clavicle with complete displacement have a high non-union rate and are associated with poor functional outcomes following
Objectives. The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to
The increasing prevalence of osteoporosis in
an ageing population has contributed to older patients becoming
the fastest-growing group presenting with acetabular fractures.
We performed a systematic review of the literature involving a number
of databases to identify studies that included the treatment outcome
of acetabular fractures in patients aged >
55 years. An initial
search identified 61 studies; after exclusion by two independent
reviewers, 15 studies were considered to meet the inclusion criteria.
All were case series. The mean Coleman score for methodological
quality assessment was 37 (25 to 49). There were 415 fractures in
414 patients. Pooled analysis revealed a mean age of 71.8 years
(55 to 96) and a mean follow-up of 47.3 months (1 to 210). In seven
studies the results of open reduction and internal fixation (ORIF)
were presented: this was combined with simultaneous hip replacement
(THR) in four, and one study had a mixture of these strategies.
The results of percutaneous fixation were presented in two studies,
and a single study revealed the results of
A high rate of complications is associated with open reduction and internal fixation of Sanders type 4 fractures of the calcaneum. We assessed the long-term outcome of 83 Sanders type 4 comminuted intra-articular fractures of the calcaneum in 64 patients who underwent
Isolated Weber B fractures usually heal uneventfully but traditionally require regular review due to the possibility of medial ligament injury allowing displacement. Following recent studies suggesting that delayed talar shift is uncommon we introduced a functional treatment protocol and present the early results. 86 patients presenting acutely with Weber B fractures without talar shift between January and July 2015 were included. Patients were splinted in a removable boot and allowed to weight bear. ED notes and radiographs were reviewed by an Orthopaedic consultant. Patients without signs of medial injury were discharged with an information leaflet and advice. If signs of medial ligament injury were noted or the medial findings were not documented the patient was reviewed in fracture clinic at 4 weeks post-injury. If talar shift developed the patient was to be converted to operative treatment. MOXFQ and EDQ5 scores were collected. 50 patients had signs of medial ligament injury or no documented medial findings and of these 43 attended fracture clinic. Of 36 patients without signs of medial ligament injury 28 were discharged according to protocol and 8 patients attended fracture clinic. One discharged patient re-accessed care. Of 52 patients reviewed in the fracture clinic none developed delayed talar shift and all continued with
Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England. We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1 February 2019 and 31 October 2020 in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England’s SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models.Aims
Methods
Management of irreparable rotator cuff tears is challenging and controversial. Surgeons have been utilising biological tissue scaffolding to augment repairs, but there are concerns regarding viability and function. We wished to investigate this viability and clinical outcome in a small group of patients. All procedures were performed by a single surgeon over a three-year period. Inclusion criteria were patients with large cuff tears and failure of
Frozen shoulder is a common condition that affects the working population. The longevity and severity of symptoms often results in great economic burden to health services and absence from work. This prospective cohort study aimed to investigate whether early intervention with arthroscopic capsular release resulted in improvement of symptoms and any potential economic benefit to society. Patients were recruited prospectively. Data was gathered by way of questionnaire to ascertain demographics, previous primary care treatment and absence from work. Oxford Shoulder Score (OSS) was also calculated. Arthroscopic capsular release was performed and further data gathered at four week post-operative follow up. Economic impact of delay to treatment and cost of intervention was calculated using government data from the national tariff which costs different forms of treatment. Statistical analysis was then performed on the results. Twenty five patients enrolled. Mean pre-operative OSS: 37.4 (range 27–58, SD 7.4). Mean post-operative OSS: 15.9 (range 12–22, SD 2.3). P<0.01. Mean improvement in OSS: 21.5 (range 12–38, SD 7.1). The cost of
We performed a prospective, randomised controlled trial of the operative versus
This multi-centre single-blind randomised control trial compared outcomes in patients with acute displaced mid-shaft clavicle fractures treated either by primary open reduction and plate fixation (ORPF), or
To assess the stability of the hip after acetabular fracture, dynamic fluoroscopic stress views were taken of 41 acetabular fractures that met the criteria for non-operative management. These included roof arcs of 45°, a subchondral CT arc of 10 mm, displacement of less than 50% of the posterior wall, and congruence on the AP and Judet views of the hip. There were three unstable hips which were treated by open reduction and internal fixation. The remaining 38 fractures were treated non-operatively with early mobilisation and delayed weight-bearing. At a mean follow-up of 2.7 years, the results were good or excellent in 91% of the cases. Three fair results were ascribed to the patients’ other injuries. Dynamic stress views can identify subtle instability in patients who would normally be considered for
We describe 24 fractures of the tuberosity of the calcaneus in 22 patients. Three were similar to the type of avulsion fracture which has been well-defined but the remainder represent a group which has been unrecognised previously. Using CT and operative findings we have defined the different patterns of fracture of the calcaneal tuberosity. Ten fractures extended into the subtalar joint, but did not fit the pattern of the common intra-articular fracture as described classically. We have defined a new pattern which consists of a fracture of the medial calcaneal process with a further fracture which separates the upper part of the tuberosity in the semicoronal plane.
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. 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.Aims
Patients and Methods