Aims. Proximal humeral fractures (PHFs) are common. There is increasing evidence that most of these fractures should be treated conservatively. However, recent studies have shown an increase in use of operative treatment. The aim of this study was to identify the trends in the incidence and methods of treatment of PHFs in Finland. Methods. The study included all Finnish inhabitants aged ≥ 16 years between 1997 and 2019. All records, including diagnostic codes for PHFs and all surgical procedure codes for these fractures, were identified from two national registers. Data exclusion criteria were implemented in order to identify only acute PHFs, and the operations performed to treat them. Results. During the 23-year study period, 79,676 PHFs were identified, and 14,941 operations were performed to treat them. The incidence of PHFs steadily increased. In 2019, the overall incidence was 105 per 100,000 person-years (10. 5. ). The sex-adjusted incidence for females was 147.1 per 10. 5. , and the age-adjusted incidence for patients aged ≥ 80 years was 407.1 per 10. 5. The incidence of operative treatment for PHFs rose during the first half of the study period and decreased during the second half. The use of plate osteosynthesis in particular decreased. In 2019, the incidence of operative treatment for PHFs was 13.2 per 10. 5. , with 604 operations. Conclusion. Although the incidence of PHFs is steadily increasing, particularly in elderly females, the incidence of operative treatment is now decreasing, which is in line with current literature regarding their treatment. Cite this article: Bone Joint J 2022;104-B(1):150–156

This prospective randomised trial aimed to assess the superiority of internal fixation of well-reduced medial malleolar fractures (displacement □2mm) compared with non-fixation, following fibular stabilisation in patients undergoing surgical management of a closed unstable ankle fracture.

A total of 154 adult patients with a bi- or trimalleolar fracture were recruited from a single centre. Open injuries and vertically unstable medial malleolar fractures were excluded. Following fibular stabilisation, patients were randomised intra-operatively on a 1:1 basis to fixation or non-fixation after satisfactory fluoroscopic fracture reduction was confirmed. The primary outcome was the Olerud Molander Ankle Score (OMAS) at 12 months post-randomisation. Complications were documented over the follow-up period.

The baseline group demographics and injury characteristics were comparable. There were 144 patients reviewed at the primary outcome point (94%). The median OMAS was 80 (IQR, 60-90) in the fixation group vs. 72.5 (IQR, 55-90) in the non-fixation group (p=0.165). Complication rates were comparable, although significantly more patients (n=13, 20%) in the non-fixation group developed a radiographic non-union (p<0.001). The majority (n=8/13) were asymptomatic, with one patient requiring surgical reintervention. In the non-fixation group, a superior outcome was associated with an anatomical medial malleolar fracture reduction.

Internal fixation is not superior to non-fixation of well-reduced medial malleolar fractures when managing unstable ankle fractures. However, one in five patients following non-fixation developed a radiographic non-union and whilst the re-intervention rate to manage this was low, the longer-term consequences of this are unknown. The results of this trial may support selective non-fixation of anatomically reduced fractures.

Aims. This is a multicentre, prospective assessment of a proportion of the overall orthopaedic trauma caseload of the UK. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements. Methods. Data capture was by collaborative approach. Patients undergoing procedures from 22 August 2022 and operated on before 31 October 2022 were included. Arm one captured weekly caseload and theatre capacity. Arm two concerned patient and injury demographics, and time to surgery for specific injury groups. Results. Data was available from 90 hospitals across 86 data access groups (70 in England, two in Wales, ten in Scotland, and four in Northern Ireland). After exclusions, 709 weeks' of data on theatre capacity and 23,138 operations were analyzed. The average number of cases per operating session was 1.73. Only 5.8% of all theatre sessions were dedicated day surgery sessions, despite 29% of general trauma patients being eligible for such pathways. In addition, 12.3% of patients experienced at least one cancellation. Delays to surgery were longest in Northern Ireland and shortest in England and Scotland. There was marked variance across all fracture types. Open fractures and fragility hip fractures, influenced by guidelines and performance renumeration, had short waits, and varied least. In all, nine hospitals had 40 or more patients waiting for surgery every week, while seven had less than five. Conclusion. There is great variability in operative demand and list provision seen in this study of 90 UK hospitals. There is marked variation in nearly all injuries apart from those associated with performance monitoring. There is no evidence of local network level coordination of care for orthopaedic trauma patients. Day case operating and pathways of care are underused and are an important area for service improvement. Cite this article: Bone Jt Open 2023;4(6):463–471

Aims. To compare the functionality of adults with displaced mid-shaft clavicular fractures treated either operatively or nonoperatively and to compare the relative risk of nonunion and reoperation between the two groups. Methods. Based on specific eligibility criteria, 120 adults (median age 37.5 years (interquartile range (18 to 61)) and 84% males (n = 101)) diagnosed with an acute displaced mid-shaft fracture were recruited, and randomized to either the operative (n = 60) or nonoperative (n = 60) treatment group. This randomized controlled, partially blinded trial followed patients for 12 months following initial treatment. Functionality was assessed by the Constant score (CS) (assessor blinded to treatment) and Disability of the Arm, Shoulder and Hand (DASH) score. Clinical and radiological evaluation, and review of patient files for complications and reoperations, were added as secondary outcomes. Results. At 12 months, 87.5% of patients (n = 105) were available for analysis. The two groups were well balanced based on demographic and fracture-related characteristics. At six weeks of follow-up a significant difference in DASH score (p < 0.001) was found in favour of operative treatment. The functionality at 12 months of follow-up based on CS and DASH was excellent in both groups (CS > 90 points and DASH < 10 points) with no significant difference (p = 0.277 for DASH and p = 0.184 for CS) between the two groups. The risk of symptomatic nonunion was significantly higher in the nonoperative group (p = 0.014), with a relative risk of 9.47 (95% confidence interval (CI) 1.26 to 71.53) in this group compared to the operative group. The number-needed-to-treat to avoid one symptomatic nonunion was 6.2. Initial treatment and age were factors significantly associated with nonunion in a logistic analysis. There were 26% in both groups (n = 14 in operative group and n = 15 in nonoperative group) who required secondary surgery, with most indications in the nonoperative group mandatory due to nonunion compared to most relative indications in the operative group requiring intervention due to implant irritation. Conclusion. Superiority was not identified with either an all-operative or all-nonoperative approach. The functionality at short term (within six weeks) seems igreater following operative treatment but was not found at one year. The risk of nonunion is significantly higher with nonoperative treatment. However, an all-operative approach to lower the nonunion risk may result in unnecessary surgery and is not recommended. Cite this article: Bone Joint J 2021;103-B(4):762–768

Global surgical literature suggests that female trainees have less operative autonomy than their male counterparts. This pilot study had the primary objective to identify difference in autonomy by gender, and to power a national study to carry out further quantitative and qualitative research on this. This was a retrospective, cross-sectional study utilising eLogbook data for all orthopaedic trainees (ST2-8) and consultants with CCT date 2016–2021 in a single Scottish deanery. The primary outcome measure was percentage of procedures undertaken as lead surgeon. 15 trainees and four recent consultants participated, of which 12 (63%) were male (mean grade 5.2), and 7 (37%) were female (mean grade 4.3). Trainees were lead surgeon on 64% of procedures (17595/27558), with autonomy rising with grade (37% ST1 to 85% ST8, OR 9.4). Operative autonomy was higher in male vs female trainees (66.5% and 61.4% respectively, p=<0.0001), with female trainees more likely to operate with a supervisor present (STU/S vs P/T, f 48%:13%, m 45%:20%). This pilot study found that there was a significant difference in operative autonomy between male and female trainees, however this may be explained by differences in mean grade of male vs female trainees. Five trainees took time OOT, 4/5 of whom were female. Extension to a national multi-centre study should repeat the quantitative method of this study with additional qualitative analysis including assessing effect of time OOT to explore the reason for any gender discrepancies seen across different deaneries in the UK

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

This single-centre prospective randomised trial aimed to assess the superiority of operative fixation compared with non-operative management for adults with an isolated, closed humeral shaft fracture. 70 patients were randomly allocated to either open reduction and internal fixation (51%, n=36/70) or functional bracing (49%, n=34/70). 7 patients did not receive their assigned treatment (operative n=5/32, non-operative n=2/32); results were analysed based upon intention-to-treat. The primary outcome measure was the DASH score at 3 months. Secondary outcomes included treatment complications, union/nonunion, shoulder/elbow range of motion, pain and health-related quality of life (HRQoL). At 3 months, 66 patients (94%) were available for follow-up; the mean DASH favoured surgery (operative 24.5, non-operative 39.4; p=0.006) and the difference (14.9 points) exceeded the MCID. Surgery was also associated with a superior DASH at 6wks (operative 38.4, non-operative 53.1; p=0.005) but not at 6 months or 1yr. Brace-related dermatitis affected 7 patients (operative 3%, non-operative 18%; OR 7.8, p=0.049) but there were no differences in other complications. 8 patients (11%) developed a nonunion (operative 6%, non-operative 18%; OR 3.8, p=0.140). Surgery was associated with superior early shoulder/elbow range of motion, and pain, EuroQol and SF-12 Mental Component Summary scores. There were no other differences in outcomes between groups. Surgery confers early advantages over bracing, in terms of upper limb function, shoulder/elbow range of motion, pain and HRQoL. However, these benefits should be considered in the context of potential operative risks and the absence of any difference in patient-reported outcomes at 1yr

Aims. Acetabular fractures in older adults lead to a high risk of mortality and morbidity. However, only limited data have been published documenting functional outcomes in such patients. The aims of this study were to describe outcomes in patients aged 60 years and older with operatively managed acetabular fractures, and to establish predictors of conversion to total hip arthroplasty (THA). Methods. We conducted a retrospective, registry-based study of 80 patients aged 60 years and older with acetabular fractures treated surgically at The Alfred and Royal Melbourne Hospital. We reviewed charts and radiological investigations and performed patient interviews/examinations and functional outcome scoring. Data were provided by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Survival analysis was used to describe conversion to THA in the group of patients who initially underwent open reduction and internal fixation (ORIF). Multivariate regression analyses were performed to identify factors associated with conversion to THA. Results. Seven patients (8.8%) had died at a median follow-up of 18 months (interquartile range (IQR) 12 to 25), of whom four were in the acute THA group. Eight patients (10%) underwent acute THA. Of the patients who underwent ORIF, 17/72 (23.6%) required conversion to THA at a median of 10.5 months (IQR 4.0 to 32.0) . After controlling for other factors, transport-related cases had an 88% lower rate of conversion to THA (hazard ratio (HR) 0.12, 95% confidence interval (CI) 0.02 to 0.91). Mean standardized Physical Component Summary Score (PCS-12) of the 12-Item Short Form Health Survey (SF-12) was comparable with the general population (age-/sex-matched) by 12 to 24 months. Over half of patients working prior to injury (14/26) returned to work by six months and two-thirds of patients (19/27) by 12 months. Conclusion. Patients over 60 years of age managed operatively for displaced acetabular fractures had a relatively high mortality rate and a high conversion rate to THA in the ORIF group but, overall, patients who survived had mean PCS-12 scores that improved over two years and were comparable with controls. Cite this article: Bone Joint J 2020;102-B(12):1735–1742

The primary aim was to identify patient and injury factors independently associated with humeral diaphyseal fracture nonunion after non-operative management. The secondary aim was to determine the effect of management (operative/non-operative) on nonunion. Over a ten-year period, 734 humeral diaphyseal fractures (732 consecutive patients) were retrospectively identified from a trauma database. Follow-up was available for 663 fractures (662 patients; median age 57yrs [16–96], 54% female [n=359/662]) which formed the study cohort. Patient and injury characteristics were recorded. There were 523 patients (79%) managed non-operatively and 139 (21%) managed operatively. Outcome (union/nonunion) was determined from medical records and radiographs. Median follow-up was five months (1.2–74). Nonunion occurred in 22.7% of non-operatively managed injuries (n=119/524). Multivariate analysis demonstrated pre-injury NSAIDs (adjusted OR [AOR] 40.8, 95% CI 2.6–632.3; p=0.008), being underweight (BMI <18.5kg/m2; AOR 7.3, 95% CI 1.3 to 40.2; p=0.022), overweight (BMI 25–29.9kg/m2; AOR 2.5, 95% CI 1.1 to 5.9; p=0.034) and class II obesity (BMI 35–39.9kg/m2; AOR 4.5, 95% CI 1.4 to 15.5; p=0.014) were independently associated with an increased risk of nonunion. Operative fixation was independently associated with a lower risk of nonunion (2.9%, n=4/139) than non-operative management (AOR for non-operative/operative 11.0, 95% CI 2.8 to 43.6; p=0.001). Based upon these results, five patients would need to undergo operative fixation to avoid one nonunion. Pre-injury NSAIDs and BMI were independently associated with nonunion following non-operative management of a humeral diaphyseal fracture. Operative fixation was the independent factor most strongly associated with a lower risk of nonunion

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

Aims. The aim of this prospective randomised controlled trial was to compare non-operative and operative management for acute isolated displaced fractures of the olecranon in patients aged ≥ 75 years. Patients and Methods. Patients were randomised to either non-operative management or operative management with either tension-band wiring or fixation with a plate. They were reviewed at six weeks, three and six months and one year after the injury. The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at one year. Results. A total of 19 patients were randomised to non-operative (n = 8) or operative (n = 11; tension-band wiring (n = 9), plate (n = 2)) management. The trial was stopped prematurely as the rate of complications (nine out of 11, 81.8%) in the operative group was considered to be unacceptable. There was, however, no difference in the mean DASH scores between the groups at all times. The mean score was 23 (0 to 59.6) in the non-operative group and 22 (2.5 to 57.8) in the operative group, one year after the injury (p = 0.763). There was no significant difference between groups in the secondary outcome measures of the Broberg and Morrey Score or the Mayo Elbow Score at any time during the one year following injury (all p ≥ 0.05). . Conclusion. These data further support the role of primary non-operative management of isolated displaced fractures of the olecranon in the elderly. However, the non-inferiority of non-operative management cannot be proved as the trial was stopped prematurely. Cite this article: Bone Joint J 2017;99-B:964–72

Background. We compared pain relief after total hip arthroplasty using periarticular intraoperative injection along with single dose post operative injection of local anesthetic (THA) with the well-established practice of epidural infusion. Methods. 70 patients undergoing elective THA under combined spinal anaesthesia were randomly assigned to receive either (1) continuous epidural infusion (group B) or (2) infiltration around the hip joint with a mixture of 100 ml of bupivacaine (2 mg/ml) + 1ml ketorolac (30mg/ml) and 0.5ml epinephrine (1mg/ml) at the conclusion of surgery combined with one postoperative intraarticular injection of 20 ml. of Bupivacaine 0.5% + 1ml ketorolac (30mg/ml)+ 0.5 ml. epinephrine (1mg/ml) through an intraarticular catheter (group A). All patients received acetoaminophen 1gm 8 hourly for 72 hrs and injection ketoralac 30mg every 6 hourly IV(15mg if >65 yr 30mg if <65 yr). Breakthrough pain in any group (VAS >7) was treated by injection fentanyl 20 μg bolus at 10 min. interval till VAS reduced to < 4. If VAS 4–7 injection tramadol 50mg IV was given if VAS continued to be >4 after 15 min. then injection fentanyl 20 μg bolus was given at 10 min interval till VAS <4. Results. Narcotic consumption was significantly reduced in group A compared to group B (p=0.007). Pain levels at rest and during mobilization were similar in both groups during first 24 hrs but significantly reduced in group A after cessation of treatment. Interpretation. Wound infiltration combined with intraarticular injection of local Anaesthetics provides good pain relief for patients undergoing THA

Aims. 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. Patients and Methods. 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. Results. OSS data were available for 164, 155 and 149 participants at three, four and five years, respectively. There were no statistically or clinically significant differences between operative and non-operative treatment at each follow-up point. No participant had secondary shoulder surgery for a new complication. Analyses of EQ-5D-3L data showed no significant between-group differences in quality of life over time. Conclusion. These results confirm that the main findings of the PROFHER trial over two years are unchanged at five years. Cite this article: Bone Joint J 2017;99-B:383–92

The aim of this study was to investigate the epidemiology of fractures of the distal radius in the Swedish population and to review the methods used to treat them between 2005 and 2010. The study population consisted of every patient in Sweden who was diagnosed with a fracture of the wrist between 1 January 2005 and 31 December 2010. There were 177 893 fractures of the distal radius. The incidence rate in the total population was 32 per 10 000 person-years. The mean age of the patients was 44 years (0 to 104). The proportion of fractures treated operatively increased from 16% in 2005 to 20% in 2010. The incidence rate for plate fixation in the adult population increased 3.61 fold. The incidence rate for external fixation decreased by 67%. The change was greatest in the 50 years to 74 years age group. In Sweden, there is an increasing tendency to operate on fractures of the distal radius. The previously reported increase in the use of plating is confirmed: it has increased more than threefold over a five-year period. Cite this article: Bone Joint J 2014;96-B:963–9

Introduction. Because it typically afflicts older patients with poorer health and/or risk factors, spondylodiscitis can become life threatening. Lingering symptoms, which can be attributed to residual destruction as well as concurrent degenerative changes in the adjacent segments after inflammation has subsided, are frequently present after both conservative and operative therapies. Here, quality of life outcomes are presented for patients two years after operative and conservative treatment. Methods. 82 patients with spondylodiscitis were included prospectively from 01/2008. 28% of patients were treated conservatively (Group 1) and 72% operatively (Group 2). Clinical findings, SF-36, ODI, COMI, and a visual analog scale (VAS) were evaluated and compared between the groups at admission and follow-up (2 year FU). Results. Average patient age was 64.9 ± 6.3 years. Average inpatient hospital stay was 26.5 ± 16.9 days. Neurologic deficits were present in 39.0% of patients preoperatively and 18.3% at FU. Abscess formation was diagnosed in 89.0% of cases and intraspinal abscesses in 43.9%. Hospital mortality was 11.0% and total mortality 14.6% at FU. 6.1% of cases were lost to FU. The preoperative ODI scores averaged 75.4 ± 16.6, and did not vary significantly between the groups. At FU, with 33.9 ± 21.2, average score was significantly better (p<0.001). On the SF-36, preoperative average scores were PCS 25.7 ± 7.1 and MCS 37.3 ± 13.4, and at FU PCS 43.5 ± 10.1 (p<0.05) and MCS 47.7 ± 14.8 (p<0.05). COMI scores also showed significant (p<0.001) improvement (preoperatively 9.2 ± 1.0 and at FU 3.5 ± 2.2). On comparison, patients in Group 2 (VAS 8.3) preoperatively had more pain (p<0.05) than those in Group 1 (VAS 6.3), but there was no significant difference at FU (group 2 VAS 2.5 and group 1 VAS 3.0). Over 90% of operated patients reported that treatment helped, while over 30% of conservatively treated patients said that treatment helped a little or not at all. Discussion. In the pre-antibiotics era, the prognosis for spondylodiscitis was poor. Currently, it can still lead to serious health problems and become life threatening. Quality of life and physical limitations are markedly worse than for the general population. Compared to patients treated conservatively, patients treated with surgery have somewhat improved quality of life and significantly better patient satisfaction

Consecutive patients with a confirmed rupture of at least one of the lateral ligaments of the ankle were randomly assigned to receive either operative or functional treatment. They were evaluated at a median of 8 years (6 to 11). In total, 370 patients were included. Follow-up was available for 317 (86%). Fewer patients allocated to operative treatment reported residual pain compared with those who had been allocated to functional treatment (16% versus 25%, RR 0.64, CI 041 to 1.0). Fewer surgically-treated patients reported symptoms of giving way (20% versus 32%, RR 0.62, CI 0.42 to 0.92) and recurrent sprains (22% versus 34%, RR 0.66, CI 0.45 to 0.94). The anterior drawer test was less frequently positive in surgically-treated patients (30% versus 54%, RR 0.54, CI 0.41 to 0.72). The median Povacz score was significantly higher in the operative group (26 versus 22, p < 0.001). Compared with functional treatment, operative treatment gives a better long-term outcome in terms of residual pain, recurrent sprains and stability

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 non-operative treatment for primary dislocation of the patella, regarding redislocation rates and symptoms. Methods. Based on a systematic literature search of the medical literature from 1950 to 2010, three randomized and two quasi-randomized controlled clinical trials comparing surgical stabilization with non-operative treatment for patients with primary patellar dislocation were selected. The Risk of Bias Tool (Cochrane Handbook, 2008) was used to assess the quality of the studies included. Study results were pooled using the fixed-effects and random-effects models with mean differences and risk ratios for continuous and dichotomous variables, respectively. Heterogeneity across studies was assessed with Q test and I-square statistic. A sensitivity analysis was performed by assessing the change on effect size by eliminating each single trial. Results. In total, 341 patients from 5 trials were included. 158 patients were treated non-operatively and 183 patients were treated operatively. For primary outcome of patellar redislocation, while significant heterogeneity was found using the random-effects model, no significant difference was observed between the treatment groups (pooled RR=1.36, 95% CI 0.8–2.31, p=0.25). No significant difference was observed between the treatment groups (pooled RR=1.36, 95% CI0.8–2.31, p=0.25). No significant differences were found between both groups for symptoms ofinstability (RR of 1.24, 95% CI 0.96–1.59, p=0.10), Kujala knee score (−5.66, 95% CI −15.51 −4.19, p=0.26) or requirement for later surgery (RR=0.92, CI 0.61–1.39, p=0.69). Conclusions. This meta-analysis found no differences in patellar redislocation rate, patient reported instability symptoms, Kujala Knee score and rate of later surgery after initial treatment, between operative and non-operative treatment of primary patellar dislocation. Level of evidence. Level II

Accurate documentation of operative findings is a fundamentally important part of any procedure and forms part of the Royal College of Surgeons of England's guidelines to good care, especially to “ensure that there are legible operative notes (typed if possible) for every operative procedure.” However, many hospitals fall short of this guideline when it comes to arthroscopic procedures because of the difficulty in reproducing visually representative and easy-to-understand images. There is an inability to properly record and archive findings of arthroscopic procedures. We, along with the British Orthopaedic Association, have developed an interactive, free Web-based operative note template that allows the surgeon to draw findings on diagrams of the joints commonly undergoing arthroscopy, type the findings, and then print as many copies as required. The use of the forms has allowed for quicker, easier, and more accurate documentation of arthroscopic procedures. The forms can then be saved to a database and used as a research tool

Both conservative and operative forms of treatment have been recommended for patients with a ‘floating shoulder’. We compared the results of conservative and operative treatment in 25 patients with this injury and investigated the use of the glenopolar angle (GPA) as an indicator of the functional outcome. A total of 13 patients (ten male and three female; mean age 32.5 years (24.7 to 40.4)) were treated conservatively and 12 patients (ten male and two female; mean age 33.67 years (24.6 to 42.7)) were treated operatively by fixation of the clavicular fracture alone. Outcome was assessed using the Herscovici score, which was also related to changes in the GPA at one year post-operatively. The mean Herscovici score was significantly better three months and two years after the injury in the operative group (p < 0.001 and p = 0.003, respectively). There was a negative correlation between the change in GPA and the Herscovici score at two years follow-up in both the conservative and operative groups, but neither were statistically significant (r = -0.295 and r = -0.19, respectively). There was a significant difference between the pre- and post-operative GPA in the operative group (p = 0.017). When compared with conservative treatment, fixation of the clavicle alone gives better results in the treatment of patients with a floating shoulder. The GPA changes significantly with fixation of clavicle alone but there is no significant correlation between the pre-injury GPA and the final clinical outcome in these patients. Cite this article: Bone Joint J 2013;95-B:815–19

Objectives. The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures. The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics, injury characteristics and the nature of the surgical treatment. Methods. A total of ten consecutive patients undergoing surgery for the treatment of a proximal humeral fracture from each of 11 United Kingdom hospitals were retrospectively identified over a 15 month period between January 2014 and March 2015. Data gathered for the 110 patients included patient demographics, injury characteristics, mode of surgical fixation, the grade of operating surgeon and the cost of the surgical implants. Results. A majority of the patients were female (66%, 73 of 110). The mean patient age was 62 years (range 18 to 89). A majority of patients met the inclusion criteria for the PROFHER trial (75%, 83 of 110). Plate fixation was the most common mode of surgery (68%, 75 patients), followed by intramedullary fixation (12%, 13 patients), reverse shoulder arthroplasty (10%, 11 patients) and hemiarthroplasty (7%, eight patients). The consultant was either the primary operating surgeon or supervising the operating surgeon in a large majority of cases (91%, 100 patients). Implant costs for plate fixation were significantly less than both hemiarthroplasty (p < 0.05) and reverse shoulder arthroplasty (p < 0.0001). Implant costs for intramedullary fixation were significantly less than plate fixation (p < 0.01), hemiarthroplasty (p < 0.0001) and reverse shoulder arthroplasty (p < 0.0001). Conclusions. Our study has shown that the majority of a representative sample of patients currently undergoing surgical treatment for a proximal humeral fracture in these United Kingdom centres met the inclusion criteria for the PROFHER trial and that a proportion of these patients may, therefore, have been effectively managed non-operatively. Cite this article: Mr B. J. F. Dean. A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change? Bone Joint Res 2016;5:178–184. DOI: 10.1302/2046-3758.55.2000596