Aims. Perthes’ disease is a condition leading to necrosis of the femoral head. It is most common in children aged four to nine years, affecting around one per 1,200 children in the UK. Management typically includes non-surgical treatment options, such as physiotherapy with/without surgical intervention. However, there is significant variation in care with no consensus on the most effective treatment option. Methods. This systematic review aims to evaluate the effectiveness of non-surgical interventions for the treatment of Perthes’ disease. Comparative studies (experimental or observational) of any non-surgical intervention compared directly with any alternative intervention (surgical, non-surgical or no intervention) were identified from: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMcare, Allied and Complementary Medicine Database (AMED), and the Physiotherapy Evidence Database (PEDro). Data were extracted on interventions compared and methodological quality. For post-intervention primary outcome of radiological scores (Stulberg and/or Mose), event rates for poor scores were calculated with significance values. Secondary outcomes included functional measures, such as range of movement, and patient-reported outcomes such as health-related quality of life. Results. In all, 15 studies (1,745 participants) were eligible for inclusion: eight prospective cohort studies, seven retrospective cohort studies, and no randomized controlled trials were identified. Non-surgical interventions largely focused on orthotic management (14/15 studies) and physical interventions such as muscle strengthening or stretching (5/15 studies). Most studies were of high/unknown risk of bias, and the range of patient outcomes was very limited, as was reporting of treatment protocols. Similar proportions of children achieving poor radiological outcomes were found for orthotic management and physical interventions, such as physiotherapy or weightbearing alteration, compared with surgical interventions or no intervention. Conclusion. Evidence from non-randomized studies found no robust evidence regarding the most effective non-surgical interventions for the treatment of children with Perthes’ disease. Future research, employing randomized trial designs, and reporting a wider range of patient outcomes is urgently needed to inform clinical practice. Cite this article: Bone Jt Open 2020;1-12:720–730

Aims. The aim of this study was to produce clinical consensus recommendations about the non-surgical treatment of children with Perthes’ disease. The recommendations are intended to support clinical practice in a condition for which there is no robust evidence to guide optimal care. Methods. A two-round, modified Delphi study was conducted online. An advisory group of children’s orthopaedic specialists consisting of physiotherapists, surgeons, and clinical nurse specialists designed a survey. In the first round, participants also had the opportunity to suggest new statements. The survey included statements related to ‘Exercises’, ‘Physical activity’, ‘Education/information sharing’, ‘Input from other services’, and ‘Monitoring assessments’. The survey was shared with clinicians who regularly treat children with Perthes’ disease in the UK using clinically relevant specialist groups and social media. A predetermined threshold of ≥ 75% for consensus was used for recommendation, with a threshold of between 70% and 75% being considered as ‘points to consider’. Results. A total of 40 participants took part in the first round, of whom 31 completed the second round. A total of 87 statements were generated by the advisory group and included in the first round, at the end of which 31 achieved consensus and were removed from the survey, and an additional four statements were generated. A total of 60 statements were included in the second round and 45 achieved the threshold for consensus from both rounds, with three achieving the threshold for ‘points to consider’. The recommendations predominantly included self-management, particularly relating to advice about exercise and education for children with Perthes’ disease and their families. Conclusion. Children’s orthopaedic specialists have reached consensus on recommendations for non-surgical treatment in Perthes’ disease. These statements will support decisions made in clinical practice and act as a foundation to support clinicians in the absence of robust evidence. The dissemination of these findings and the best way of delivering this care needs careful consideration, which we will continue to explore. Cite this article: Bone Joint J 2024;106-B(5):501–507

Data was collected for patients referred to the orthopaedic department at Forth Valley Royal Hospital with metatarsalgia who subsequently received an ultrasound. Patients found to have a Morton's neuroma were divided into groups based on its size. A total of 90 patients received an ultrasound scan and neuroma was confirmed in 58 with an alternative diagnosis found in 32 patients and a total of 42 were included in the final analysis. All 14 patients with neuroma < 6mm reported resolution of symptoms. 4 (28.5%) underwent surgical excision as first line, 1 (7%) received a single corticosteroid injection and 9 (64%) were treated with metatarsal bars. There were 27 patients with neuroma > 6mm; 8 (29.6%) underwent surgical excision as first line treatment, 5 (18.5%) received metatarsal bars and 14 (51.9%) received injections. 7 (25.9%) patients reported resolution of symptoms after 1 injection, 1 (3.7%) patient required 2 injections and 1 (3.7%) patient required 3 injections to achieve resolution. 5 (18.5%) patients required surgical excision following ongoing symptoms despite non-surgical treatment. 9 (33.3%) reported resolution of symptoms following injection. 5 (18.5%) reported resolution of symptoms following use of metatarsal bars. A total of 71% of patients with a neuroma measuring < 6mm reported full resolution of symptoms with non-surgical treatment. For patients with neuroma >6mm, 64.3% had resolution of symptoms with injections alone and 18.5% required surgical excision despite injection. In conclusion, there is a benefit to offering non-surgical treatment as first line in patients with a neuroma regardless of size

Aims. To benchmark the radiation dose to patients during the course of treatment for a spinal deformity. Methods. Our radiation dose database identified 25,745 exposures of 6,017 children (under 18 years of age) and adults treated for a spinal deformity between 1 January 2008 and 31 December 2016. Patients were divided into surgical (974 patients) and non-surgical (5,043 patients) cohorts. We documented the number and doses of ionizing radiation imaging events (radiographs, CT scans, or intraoperative fluoroscopy) for each patient. All the doses for plain radiographs, CT scans, and intraoperative fluoroscopy were combined into a single effective dose by a medical physicist (milliSivert (mSv)). Results. There were more ionizing radiation-based imaging events and higher radiation dose exposures in the surgical group than in the non-surgical group (p < 0.001). The difference in effective dose for children between the surgical and non-surgical groups was statistically significant, the surgical group being significantly higher (p < 0.001). This led to a higher estimated risk of cancer induction for the surgical group (1:222 surgical vs 1:1,418 non-surgical). However, the dose difference for adults was not statistically different between the surgical and non-surgical groups. In all cases the effective dose received by all cohorts was significantly higher than that from exposure to natural background radiation. Conclusion. The treatment of spinal deformity is radiation-heavy. The dose exposure is several times higher when surgical treatment is undertaken. Clinicians should be aware of this and review their practices in order to reduce the radiation dose where possible. Cite this article: Bone Joint J 2021;103-B(4):1–7

Aims. Fractures of the humeral shaft represent 3% to 5% of all fractures. The most common treatment for isolated humeral diaphysis fractures in the UK is non-operative using functional bracing, which carries a low risk of complications, but is associated with a longer healing time and a greater risk of nonunion than surgery. There is an increasing trend to surgical treatment, which may lead to quicker functional recovery and lower rates of fracture nonunion than functional bracing. However, surgery carries inherent risk, including infection, bleeding, and nerve damage. The aim of this trial is to evaluate the clinical and cost-effectiveness of functional bracing compared to surgical fixation for the treatment of humeral shaft fractures. Methods. The HUmeral SHaft (HUSH) fracture study is a multicentre, prospective randomized superiority trial of surgical versus non-surgical interventions for humeral shaft fractures in adult patients. Participants will be randomized to receive either functional bracing or surgery. With 334 participants, the trial will have 90% power to detect a clinically important difference for the Disabilities of the Arm, Shoulder and Hand questionnaire score, assuming 20% loss to follow-up. Secondary outcomes will include function, pain, quality of life, complications, cost-effectiveness, time off work, and ability to drive. Discussion. The results of this trial will provide evidence regarding clinical and cost-effectiveness between surgical and non-surgical treatment of humeral shaft fractures. Ethical approval has been obtained from East of England – Cambridge Central Research Ethics Committee. Publication is anticipated to occur in 2024. Cite this article: Bone Jt Open 2024;5(4):343–349

Aims. Knee osteoarthritis (OA) is characterized by a chronic inflammatory process involving multiple cytokine pathways, leading to articular cartilage degeneration. Intra-articular therapies using pharmaceutical or autologous anti-inflammatory factors offer potential non-surgical treatment options. Autologous protein solution (APS) is one such product that uses the patient’s blood to produce a concentrate of cells and anti-inflammatory cytokines. This study evaluated the effect of a specific APS intra-articular injection (nSTRIDE) on patient-reported outcome measures compared to saline in moderate knee OA. Methods. A parallel, double-blinded, placebo-controlled randomized controlled trial was conducted, where patients with unilateral moderate knee OA (Kellgren-Lawrence grade 2 or 3) received either nSTRIDE or saline (placebo) injection to their symptomatic knee. The primary outcome was the difference in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score at 12 months post-intervention. Secondary outcomes included WOMAC component scores, Knee injury and Osteoarthritis Outcome Score (KOOS), and visual analogue scale (VAS) scores at all follow-up timepoints (three, six, and 12 months). Results. A total of 40 patients were analyzed (21 nSTRIDE; 19 saline) in the study. No significant difference was found between nSTRIDE and saline groups for WOMAC total score at 12 months (mean difference -10.4 (95% CI -24.4 to 3.6; p = 0.141). There were no significant differences in WOMAC or KOOS scores across all timepoints. VAS scores favoured the saline group for both rest and worst pain scales at 12 months post-injection (mean difference (worst) 12 months 21.5 (95% CI 6.2 to 36.8; p = 0.008); mean difference (rest) 12 months 17.8 (95% CI 2.2 to 33.4; p = 0.026)). There were no adverse events recorded in either study group. Conclusion. Our study demonstrates no significant differences between nSTRIDE and saline groups in KOOS and WOMAC scores over time. Notably, APS injection resulted in significantly worse pain symptoms at 12 months compared to saline injection. Cite this article: Bone Joint J 2024;106-B(9):907–915

Aims. A pragmatic multicentre randomised controlled trial (PROFHER) was conducted in United Kingdom National Health Service (NHS) hospitals to evaluate the clinical effectiveness and cost effectiveness of surgery compared with non-surgical treatment for displaced fractures of the proximal humerus involving the surgical neck in adults. . Methods. A cost utility analysis from the NHS perspective was performed. Differences between surgical and non-surgical treatment groups in costs and quality adjusted life years (QALYs) at two years were used to derive an estimate of the cost effectiveness of surgery using regression methods. . Results. Patients randomised to receive surgical intervention accumulated mean greater costs and marginally lower QALYs than patients randomised to non-surgery. The surgical intervention cost a mean of £1758 more per patient (95% confidence intervals (CI) £1126 to £2389). Total QALYs for the surgical group were smaller than those for non-surgery -0.0101 (95% CI -0.13 to 0.11). The probability of surgery being cost effective was less than 10% given the current NICE willingness to pay at a threshold of £20 000 for an additional QALY. The results were robust to sensitivity analyses. Discussion. The results suggest that current surgical treatment is not cost effective for the majority of displaced fractures of the proximal humerus involving the surgical neck in the United Kingdom’s NHS. Take home message: The results of this trial do not support the trend of increased surgical treatment for patients with displaced fractures of the proximal humerus involving the surgical neck within the United Kingdom NHS. Cite this article: Bone Joint J 2016;98-B:152–9

Aim: A meta-analysis of randomised controlled trials was performed to investigate the effectiveness of surgical fusion for chronic low back pain compared to non-surgical intervention. Methods: Several electronic databases (MEDLINE, EMBASE, CINAHL and Science Citation Index) were searched from 1966 to October 2005. Two authors independently extracted data. The meta-analysis comparison was based on mean difference in Oswestry disability index (ODI) change from baseline to follow up of patients undergoing surgical versus non-surgical treatment. Results: Four studies of 58 articles identified in the search were eligible with a total of 740 patients. One of the studies recruited patients with adult isthmic spondylolisthesis, whereas the other studies recruited patients with a history of chronic low back pain of at least 1 year duration. Surgical treatment involved pos-terolateral fusion with or without instrumentation and flexible stabilisation. Non-surgical treatment involved exercise programs with or without cognitive therapy. The follow-up period ranged from 1 to 2 years. The mean overall difference in ODI between the surgical and non-surgical groups was statistically in favour of surgery (mean difference of ODI: 3.90; 95% confidence interval: 0.17–7.62; p=0.04; I. 2. =21.4%). Surgical treatment was associated with a 13% pooled rate of early complications (95% confidence interval: 6–20%). Conclusion: Surgical fusion for chronic low back pain favoured an improvement in the ODI compared to non-surgical intervention; this difference in ODI is of minimal clinical importance. Furthermore, surgery is associated with a significant risk of complications. Therefore, the cumulative evidence at present does not support routine surgical fusion for the treatment of chronic low back pain

Background: Chronic low back pain is the most common complaint of the working age population. Controversy exists regarding the benefit of surgical fusion of the spine for the treatment of chronic low back pain. We performed a meta-analysis of randomised controlled trials to investigate the effectiveness of surgical fusion for chronic low back pain compared to non-surgical intervention. Methods: Several electronic databases (MEDLINE, EMBASE, CINAHL, Science Citation Index and Cochrane registry of clinical trials) were searched from 1966 to October 2005. Two authors independently extracted data on study characteristics and methodological quality and the number of patients with early complications from surgery. The random-effect meta-analysis comparison was based on the mean difference in Oswestry Disability Index (ODI) change from baseline to follow-up of patients undergoing surgical versus non-surgical treatment. Between-study heterogeneity was analyzed by means of I2. Results: Four studies of 58 articles identified in the search were eligible with a total of 740 patients. One of the studies recruited patients with adult isthmic spondy-lolisthesis, whereas the other studies recruited patients with a history of chronic low back pain of at least 1 year duration. Surgical treatment involved posterolateral fusion with or without instrumentation or flexible stabilisation. Non-surgical treatment involved exercise programs with or without cognitive therapy. The follow-up period ranged from 1 to 2 years. The pooled mean difference in ODI between the surgical and non-surgical groups was statistically in favour of surgery (mean difference of ODI: 3.90; 95% confidence interval: 0.17–7.62; p=0.04; I2=21.4%). Surgical treatment was associated with a 13% pooled rate of early complication (95% confidence interval: 6–20%, I2=66.9%). Conclusion: Surgical fusion for chronic low back pain favoured an improvement in the ODI compared to non-surgical intervention. This difference in ODI is of minimal clinical importance. Furthermore, surgery was associated with a significant risk of complications. Therefore, the cumulative evidence at present does not support routine surgical fusion for the treatment of chronic low back pain

Over the past 100 years, experimental and clinical studies have tried to accelerate fracture healing and to bring ununited fractures to union . Besides advances in surgical management, non-surgical means have been investigated. Mechanical enhancement of fracture healing using controlled micromotion has been used with some success but does not seem to have been applied to nonunions. Electrical stimulation has been found effective in hypertrophic nonunions, but less so in atrophic nonunions and in the presence of a gap; the various devices available have never gained wide acceptance for various reasons. Low-intensity pulsed ultrasound has been found effective to heal non-unions, especially hypertrophic, with a success rate around 85 % . High-energy extracorporeal shock wave therapy (ESWT) has also been found effective in non-union management, but this is still controversial and there is a need for prospective controlled studies. Biological action has also been attempted for a long time. All attempts to stimulate fracture healing using systemic drugs, diet supplementations, vitamins or hormones have been essentially unsuccessful unless when correcting a pre-existing deficiency . More recently, several molecules have demonstrated an osteoinductive capacity in animal studies; human recombinant BMP-2 is currently under investigation in clinical trials. Percutaneous injection of bone marrow into a non-union has also proved of interest, particularly following centrifugation to increase the number of osteoprogenitor cells; current research aims at selecting these cells prior to injection. To conclude, a number of non-surgical means are currently available which may be of interest to accelerate fracture healing or to heal nonunions. Some are totally non-invasive, others are minimally invasive; early results have been encouraging for several of them, but there is still a need for clinical validation using prospective controlled studies. Some of those methods may well turn into alternate solutions to surgery in the future . Cost is currently a limiting factor, as long as it is not reimbursed by national health systems in most countries

The aim of this study was to determine the outcome of patients treated with Achilles tendon rupture randomized to surgical or non-surgical treatment where both groups received the same early motion and weight bearing rehabilitation protocol. Fifty patients between the ages of 18 and 50 years with a clinical diagnosis of Achilles tendon rupture were randomized to surgical or conservative treatment. All injuries had occurred within ten days. Both groups received the same rehabilitation program with initial cast immobilization then splintage in a removable orthosis with ankle motion commencing at two weeks. Patients completed the MFAI, a validated outcome questionnaire and clinical assessment including range of motion and calf squeeze response at 2, 6 and 12 weeks, 6 months and one year. There was no difference between the surgical and non-surgical groups for difference in dorsiflexion and plantar flexion between the injured and non-injured sides. There was no difference in the MFAI quality of life scores for either treatment group. There was the same number of re-ruptures in both groups. There were no infections in the operated patients. Early motion rehabilitation after Achilles tendon rupture results in similar functional results and patient satisfaction in both surgically and non-surgically treated patients

Introduction: There is still debate on the effect of operative treatment on severe displaced intra-articular fractures of the os calcis. Operatively treatment consists of open reduction or percutanious screw fixation, with conflicting results. Although the results of either operative treatment are published, little is known about the long term results of non-surgical treatment of these difficult fractures. Patients and Methods: We analyzed the data of 35 patients with an intra-articular fracture of the oc calcis which were treated with a plaster cast between 1994 and 2006. All radiographs of the fracture and the radiograph at the latest follow-up were analyzed. All patients which could be traced were invited for a clinical examination and a radiograph. A Foot Function Index-score (FFI) and AOFAS score were recorded as clinical outcome. A regression analysis was performed with the clinical outcome (AOFAS score and FFI) as outcome and age, gender, Bohler’s and Gissane’s angles, trauma mechanism and type of fracture as predictors. Results: After a median follow-up of 10 years the mean AOFAS score was 75.8 (range29–100) and the FFI was 22.9 (range 0–71). In the regression analysis we found that none of the predictors could predict the outcome. Even the Bohler’s and Gisae angle did not predict the clinical outcome. Although there was a strong correlation between the Bohler’s angle on the lateral radiograph and the occurrence of degenerative changes in the long term follow-up, both Bohler’s angle and the degenerative changes did not correlate with the clinical measures. Conclusion: Although Bohler’s angle is a strong predictor for degenerative changes after a calcaneal fracture, both Bohler’s angle and the degenerative changes on the radiograph were not correlated with the clinical outcome

Purpose: Magnetic resonance imaging (MRI) is the diagnostic imaging modality of choice for spinal disorders. The high prevalence of “abnormal” MRI findings within asymptomatic individuals is well established, however, referrals to spine surgeons are often based on symptomatically discordant or non-surgical MRI ‘abnormalities’. The purpose of this study was to determine the prevalence of typical spine MRI abnormalities among symptomatic surgical candidates (SC) and non-surgical (NS)patients. Method: A retrospective cohort study was conducted on 1,585 patients (with a lumbar MRI) seen by a spine surgeon. The cohorts were compared in terms of the total amount, type, severity and number of levels of abnormalities on MRI. All patients were prospectively stratified regarding surgical candidacy. Results: There was no difference between the cohorts (n=722-SC / 863-NS) in terms of the total amount of structural abnormalities present (p=0.26). There was no difference in the prevalence of DDD, disc-herniation or previous surgery (p> 0.2). However, there was a higher prevalence of spinal stenosis (0.513 vs. 0.394) and spondylolisthesis (0.263 vs. 0.112) within the SC (p≤0.01). Logistic-regression showed that patients with disc-herniation, stenosis or spondylolisthesis were 1.49, 1.61 and 2.84 times more likely to be SC respectively (p≤0.001). Subjects with a report of severe/large herniation or stenosis were 3.30 and 2.25 times (p< 0.001) more likely to be SC respectively. Patients with one-level anomalies were 2.19 times (p< 0.0001) more likely to be SC. Conclusion: It is hopeful that these results will better enable non-surgeons to more effectively identify and educate patients with a higher likelihood of being surgical candidates

Fractures of the proximal humerus occur predominantly in the elderly patient population. There has been a tendency over the last 15 years to perform surgical procedures to reduce and hold these fractures while the bone and soft tissue heal. The osteoporotic nature of the bone does not allow adequate fixation of the bone and therefore fixation techniques are inadequate to allow optimal soft tissue rehabilitation. A study was performed to observe the results of non-surgically treated displaced fractures of the proximal humerus in the elderly. The encouraging results are presented and discussed. Non-surgical management of displaced fractures of the proximal humerus achieves a good functional shoulder although not normal in this predominantly sedentary population. The question arises as to quality of function after surgical management of these difficult fractures compared to non surgical management and if surgical management is indicated in these elderly usually frail patients with low demand from their shoulders

Aim. Ten years ago at the EMSOS 2000 meeting we have presented our experience concerning the non-surgical treatment of stage IIB osteosarcoma of extremities. The purpose of study was to evaluate long-term results and complications related to this non-standard and controversial treatment modality. Methods. Since 1988 definitive radiation gamma therapy (RT) in the median dose of 60 Gy was administrated to 36 patients who refused surgery after preoperative chemotherapy. Until 1999 induction consisted in 3-5 cycles of intra-arterial doxorubicin (DOX) 75 mg/m2 or cis-platin (CDDP) 120 mg/m2. Since 2000 induction comprised 4 cycles of DOX 90 mg/m2+CDDP 120 mg/m2 intra-arterially. Tumour response before local treatment was assessed non-invasively by means of X-ray, CT, MRI, angiography, 3-phase bone scans and alkaline phosphatase measurement. The end-points were overall (OS), metastases free (MFS) and local progression free (LPFS) survival at 10 years. Results. OS, MFS and LPFS by Kaplan-Meier method were 48±9%, 51±9%, and 45±11% respectively. The outcome was significantly related to response assessed before RT. In 12 good responders OS, MFS and LPFS were 74±13%, 91±9%, and 69±19% respectively compared with 29±11%, 27±11%, and 34±13% in 24 non-responders, p- value 0.03, 0.003, 0.009, respectively. In 14 patients 5 years survival after local progression and delayed surgery was 38±10%. Median survival time after local relapse was 36 months. Two types of major complications were seen: 7 pathological fractures and one osteomyelitis. 21 patients (58%) remained with a functional limb until the last examination or death. Conclusions. Long-term results were higher than expected in this radioresistant tumour. In good responders to induction chemotherapy RT could be an option for local treatment. Majority of patients had a functional limb during and long time after treatment. Isolated late local relapses did not influence considerably systemic control

Abstract. Design. A pragmatic, multicentre, parallel-group, randomised controlled trial to determine whether the intervention is superior to comparator. Setting. 20 NHS Hospitals. Population. NHS patients <60 years with moderate-severe symptomatic knee OA localised to the medial compartment in whom surgical intervention is indicated. Intervention. Surgery with medial opening wedge high tibial osteotomy (HTO) followed by standard postoperative rehabilitation based on local pathways. Comparator. Tailored non-surgical intervention delivered within an NHS physiotherapy department delivered over 6-contact sessions within a period of 4 months. Outcomes. Primary outcome - 24-month Knee Injury and Osteoarthritis Outcome Score (KOOS); Secondary outcomes - OKS, FJS-12, EQ-5D-3L, Pittsburgh Sleep Problem Scale, Return to Work, secondary surgical interventions and complications at 12 and 24 months following randomisation. Health economic evaluation - 24-month within trial analysis, and a decision analytic simulation model to account for the impacts of future knee replacements (and associated revisions), and their timing relative to retirement and employment potential. Process evaluation – to explore trial eligibility, recruitment and retention rates, acceptability of intervention implementation and patient experience of taking part/contextual factors that influence this. Follow up. 12 months and 24 months post-randomisation. Sample size. 224 patients; (90% power, 2-sided p=0.05, equivalent to a sample size of 97 per group). Allowing for 15% loss to follow up, 112 patients will be recruited to each arm of the trial. Project timelines. Start date 1 August 2022, total project duration 60 months including a 9-month, 5-site internal pilot, with a recruitment rate of 0.7 patients/site/month

Aims

The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate?

Purpose. Surgical repair is the preferred method of treatment of acute Achilles ruptures in North America because, despite a higher risk of overall complications, it offers a reduced risk of re-rupture. However, more recent trials, particularly those using functional bracing with early range of motion (ROM) have challenged this statement. This meta-analysis aims to compare surgical to conservative treatment in respect to re-rupture, overall complications, return to work, calf circumference and functional outcomes, as well as to examine the effects of early ROM on re-rupture rate. Method. Literature search, data extraction, and quality assessment were conducted by two independent reviewers. Publication bias was assessed using the Eggar and Begg tests. Heterogeneity was assessed using I2 tests. Fixed or random-effects models were used accordingly. Pooled results were expressed as risk ratios, risk differences, and weighted or standardized mean difference, as appropriate. Meta-regression was employed to identify heterogeneity causes. Sub-group analysis was performed to assess the effect of early ROM. Results. Nine study fit inclusion criteria. If early ROM is employed, re-rupture rates were equal for surgical and non-surgical patients (RD 0.6% p=0.782). If functional treatment is not employed, the absolute risk reduction achieved by surgery was 8.8% (p=0.002). Surgery was associated with an absolute risk increase of 15.7% (p=0.026) for overall complications. Surgical patients returned to work 19.16 days sooner (p=0.0014). There was no statistically significant difference between the two treatments in terms of calf circumference (p=0.357), strength (p=0.806), or functional outcomes (p=0.226). Conclusion. According our results, for centers using functional rehabilitation, conservative treatment should be preferred, as it results in similar re-rupture rates as surgical treatment, while offering the advantage of decreased overall complications. For centers that do not employ early ROM protocols, surgical repair can be considered as it decreases re-rupture risk

To investigate the effectiveness of surgical fusion for chronic low back pain (CLBP) compared to non-surgical intervention, databases were searched from 1966-2005. The meta-analysis was based on the mean difference in Oswestry Disability Index (ODI) change from baseline to follow-up. Four studies were eligible (634 patients). The pooled mean difference in ODI was 4.13 in favour of surgery (95% CI: -0.82-9.08; p=0.10; I2=44.4%). Surgery was associated with a 16% pooled rate of complication (95% CI: 12-20%, I2=0%). The cumulative evidence does not support surgical fusion for CLBP due to the marginal improvement in ODI which is of minimal clinical importance

Purpose. To compare the efficacy and safety of balloon kyphoplasty (BKP) to non-surgical management (NSM) over 24 months in patients with acute painful fractures by clinical outcomes and vertebral body kyphosis correction and surgical parameters. Material and Methods. Three hundred Adult patients with one to three VCF's were randomised within 3 months of the acute fracture; 149 to Balloon Kyphoplasty and 151 to Non-surgical management. Subjective QOL assessments and objective functional (Timed up and go [TUG]) and vertebral body kyphotic angulation (KA), were assessed over 24 months; we also report surgical parameters and adverse events temporally related to surgery (within 30-days). Results. Kyphoplasty was associated with greater improvements in SF-36 PCS scores when averaged across the 24-month follow-up period, compared with NSM (overall treatment effect 3.24points, 95% CI, 1.47–5.01; p=0.0004)., and TUG (overall treatment effect −3.00 seconds, 95% CI, −1.0 to −5.1; p<0.0043). At 24 months, the change from baseline in KA was statistically significantly improved in the kyphoplasty group (average 3.1°of correction for BKP versus 0.8°for NSM, p=0.003). On average IBT inflation volumes were consistent with cement volumes at 2.4 cc per side. The most common adverse events within 30-days were back pain, new vertebral fracture, nausea/vomiting and UTI. BKP is calculated to be cost-effective in the UK setting. Conclusions. Compared with NSM, BKP improves patient function and QOL when averaged over 24-months and results in better improvement of index vertebral body kyphotic angulation. Author potential conflicts of interest; JVM, LB; SB, DW and JR are consultants for Medtronic Spine LLC for the FREE study; JBT is currently employed by Medtronic, Inc