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

Waiting time to access medical care in Canada is 20% more than the international average. Delay in instituting care in trauma patients has been shown to correlate with higher complication rates and an increase in mortality. About 11% of all fractures occur in the femur and are usually treated operatively. Delay to operative treatment is a source of distress to patients and a major factor for poor outcome. Knowledge gaps exist for statistics on operative delay to fixation of femur fractures and the influence on complications and cost of treatment. This study describes (1) the effect of delay to fixation of femur fractures on complications and on the overall cost of care in hospitals in Quebec Province of Canada; and (2) proposes a time frame within which femur fractures should be operated on to minimize the risk of complications and reduce treatment cost. 6,520 adult patients operated for closed femoral fractures between July 1993 and December 2002 were reviewed. Data was accessed from (a) the Quebec Trauma Registry, (b) the hospitalised patients’ database, Maintenance et exploitation des données pour l’étude de la clientèle hospitalière (MED-ECHO) and (c) the medical insurance claims databases, Régie de l’assurance maladie Québec (RAMQ). Excluded were poly-trauma, open fractures, pathological fractures and delayed diagnoses beyond a week. Data was analysed using the SPSS software version 17.0. Cost analysis was carried out using parametric techniques (Student’s t-test and the generalized longitudinal model). Mean operative delay for femoral fractures was 26.3 hours. Delay was associated with increased complications, ICU stay, length of stay (LOS), hospitalization costs and out-patient follow-up treatment costs. There was a progressive increase in these adverse events which was quite significant after the first 48 hours. ISS >15 predisposed to prolonged ICU stay, LOS and increased cost of treatment. All femur fractures appeared to have a predilection for over-65-year-olds and women. The major cost drivers of operative femur fracture treatment were ISS>15, operative delay ≥48 hours, occurrence of complications, and re-operations. Minimizing operative delay in femur fractures will not only mitigate patient suffering, but also reduce treatment and follow-up costs

There were 47 patients with congenital muscular torticollis who underwent operative release. After a mean follow-up of 74 months (60 to 90), they were divided into two groups, one aged one to four years (group 1) and the other aged five to 16 years (group 2). The outcomes were assessed by evaluating the following parameters: deficits of lateral flexion and rotation, craniofacial asymmetry, surgical scarring, residual contracture, subjective evaluation and degree of head tilt. The craniofacial asymmetry, residual contracture, subjective evaluation and overall scores were similar in both groups. However, group 2 showed superior results to group 1 in terms of the deficits of movement, surgical scarring and degree of head tilt. It is recommended that operative treatment for congenital muscular torticollis is postponed until the patient can comply successfully with post-operative bracing and an exercise programme

The main objective of our review was to access the inter-net websites providing information on non operative treatment of scoliosis and to assess the evidence for each treatment in the medical literature. Methods: We identified top five search engines at the site . www.searchengines.com. The search term “scoliosis treatment” was entered into each search engine. The websites were reviewed and each search engine produced from 145,354 to 5460,000 results. We identified twenty non operative treatments for scoliosis. We further evaluated and studied these non operative treatments by using each treatment as a search term. The accuracy of these treatments was checked by doing a medical literature review. We used Medline 1950 to November 2008 and Embase 1980 to November 2008. Results: 260 websites were duplicated in the five search engines, 103 websites only mentioned surgical treatment of scoliosis, and 10 websites could not be accessed at the time of the study. We evaluated the remaining 127 websites using the key words “scoliosis treatment” to generate a list of twenty unique non operative scoliosis treatments. These treatments when entered individually into the search engines enabled us to produce a list of these treatments in decreasing order of frequency. This was based on the number of results that each treatment generated. These treatments were then entered for search in Medline and Embase, only 45% (9/20) of these treatments were found to have been described in the medical literature. Conclusion: Our study did reveal that information on non operative treatment of scoliosis leaves much to be desired. Based on this study we recommend that it is the duty of the treating surgeon to warn the patients of the potential danger of misinformation that is abundant on the internet. Ethics approval: None. Interest Statement: None

Purpose: The presentation of our experience in the operative treatment of adult idiopathic scoliosis (AIS) with different posterior instrumentation systems. Materials and methods: 195 patients with AIS, who underwent posterior instrumentation between January 1989 and December 2002 were included. Patients with degenerative scoliosis were not included in this study. 151 patients were female (77%) and 44 male (23%), with a mean age of 29 years (range, 18–68). The distribution of the lesions according to type was: 48 Th (25%), 67 Th/L (34%), 28 ThL (14%), 50 L (26%) and 2 Th/Th (1,0%). The mean preoperative Cobb angle was 52° (range, 32°–90°). The main indication for surgical treatment in older patients was unremitting pain after 15 months of conservative treatment. Preoperatively, 57% of the patients complained about pain (75% axial back pain, 25% radicular pain) and 43% about deterioration of deformity. Correction of the deformity in pre-operative lateral bending films was 43%. The systems for posterior instrumentation used were: Harrington:15, Hartshill: 26, Isola:38, Colorado:1, TSRH:35, CD-Horizon:21, Synergy:26, Moss-Miami:30, Spine evolution:1, Isobar-Isolock:2. Results: postoperative correction of the Cobb angle was 48% and subjective improvement of pain was reported by 71,2% of symptomatic patients. Postoperative complications occurred in14 patients (7%): 4 had deep wound infection, 2 had transient worsening of radicular symptoms, 1 had postoperative icterus, 1 had transient postoperative thoracic pain, 3 had implant failure that was symptomatic in 2 of them and were revised, 2 had CSF leak and 1 had postoperative back pain and had the implants removed after fusion had been achieved. Conclusion: The operative treatment of adult idiopathic scoliosis with posterior instrumentation is a safe method that provides a great amount of correction of deformity and diminishes pain in symptomatic patients

Fractures of the scapula occur mainly from direct trauma involving considerable violence and associated injuries of the shoulder and thorax are common. In most cases early functional treatment gives good or excellent results. Operative treatment may, however, be indicated, especially with displaced intra-articular fractures, fractures of the glenoid rim associated with humeral head subluxation, or unstable fractures of the scapular neck. Between 1967 and 1981, we treated 37 such fractures by open reduction and stable osteosynthesis. We were able to follow up 33 cases (89%), of which 21 (64%) had complete functional recovery. The other 12 had varying degrees of pain, loss of mobility, and weakness. Overall, however, 79% of the patients had good to excellent results

Over the past 40 years, the management of displaced fractures of the acetabulum has changed from conservative to operative. We have undertaken a meta-analysis to evaluate the classification, the incidence of complications and the functional outcome of patients who had undergone operative treatment of such injuries. We analysed a total of 3670 fractures. The most common long-term complication was osteoarthritis which occurred in approximately 20% of the patients. Other late complications, including heterotopic ossification and avascular necrosis of the femoral head, were present in less than 10%. However, only 8% of patients who were treated surgically needed a further operation, usually a hip arthroplasty, and between 75% and 80% of patients gained an excellent or good result at a mean of five years after injury. Factors influencing the functional outcome included the type of fracture and/or dislocation, damage to the femoral head, associated injuries and co-morbidity which can be considered to be non-controllable, and the timing of the operation, the surgical approach, the quality of reduction and local complications which are all controllable. The treatment of these injuries is challenging. Tertiary referrals need to be undertaken as early as possible, since the timing of surgery is of the utmost importance. It is important, at operation, to obtain the most accurate reduction of the fracture which is possible, with a minimal surgical approach, as both are related to improved outcome

From 1975 to 1988, operative treatment was performed on 50 feet in 45 patients with tarsal tunnel syndrome. The causes of this syndrome were correlated with operative findings and included ganglia in 18, and a bony prominence from talocalcaneal coalition in 15. Five feet had sustained an injury, tumours were found in three and there was no obvious cause in nine. In most cases in need of operative treatment, there was a space-occupying lesion. Classifying the results according to causes, those with coalition or a tumour fared better, and idiopathic and traumatic cases had a worse outcome. In cases with a definite lesion, an excellent result can be expected from surgical treatment carried out soon after onset of the condition

Patients with Lumbar Degenerative Kyphosis and Kyphoscoliosis (LDK) complain of stooped gait, persistent low back pain and weakness. Because operative treatment of LDK imposes considerable operative intervention for aged patients, an indication should be strictly limited; those have severe low back pain with lumbar kyphosis which afflicts upright walking disturbing house keeping, patients aged less than 70 as a rule and have no critical general complication as well. Purpose of this paper is to compare factors that affect the results of operative treatment of LDK. 19 patients were reviewed retrospectively in these series (av. aged 62.7, all female except one), who were followed-up for 3.0 years in average (14 months-8 years.) after the last surgery. Number of fused vertebra comprised 3 in 4 cases, 4 in 5, 5 in 3, 6 in 2, 7 in 2, 8 in 1, 9 in 2 respectively. In these cases 8 (av. aged 60.4) had no interbody fusion at all, one segment in one, 2 segments in 4, and 3 and more in 6 either anterior or posteriorly. Results were evaluated as excellent, good, fair and poor based on a correction rates of C7 plumb line and T1 tilt angle, as well as correction of lumbar kyphosis angle. The result was evaluated as excellent in 2 cases, good in 6, fair in 6 poor in 5. No co-relation was found between the results and number of fused vertebra at the last stage. However, patients whose operation include interbody fusion (IBF) of 3 and more contiguous segments showed either excellent or good, but all cases with single segment or no IBF groop showed either poor or fair, where those with 2 segments had good in 2 cases and fair in 2 respectively. There were relatively many poor results due to instrument failures (6 cases), insufficient correction of the deformity, compression fracture and increase of kyphosis above and below IBF level, possibly caused by progression of osteoporosis and degeneration. Four patients were found nerve root symptom after surgery, but almost healed by revision in several weeks. In order to obtain good result correction should include interbody fusion of at least 3 contiguous lumbar segments for multilevel anterior support and rigid instrumentation in sufficient length. Accurate planning before operation and careful surgical procedure should be emphasized to avoid nerve entrapment and instrument failure

Background: To improve the primary operative treatment of complex olecranon fractures we searched for new conclusive parameters. We hypothesized that the intermediate fragment plays a critical role for precise restoration of the trochlear notch contour and good outcome of initial operative treatment. Methods: 58 patients (26 female, 32 male; mean age 55 years) with multi-fragmentary olecranon fracture were identified in a seven-year-period from trauma unit files at two European Level 1 trauma institutions. Retrospective review of all operative reports and radiographs/computed tomography scans identified patients with an intermediate fragment. Results: 28 patients were treated with stable internal fixation using figure-of-eight tension-band wire fixation and 30 patients using posterior plate osteosynthesis with and without intramedullary screw. An intermediate fragment was seen in 36 patients (62 %). In 17 of these 36 patients (47 %), the intermediate fragment was described in operative report. Twelve of these patients (71 %) were treated with single posterior plate with/without an intramedullary screw, and five patients (29 %) with figure-of-eight tension-band wire fixation. Conclusion: Fracture analysis identified an intermediate fracture fragment in the majority of patients with complex olecranon fractures. In diagnostic work up a CT scan should be used to assess the fracture pattern and to detect an intermediate fragment. This study suggests that identification, desimpaction and anatomic reduction of the intermediate fragment are critical preconditions for anatomic restoration of the trochlear notch and good functional results. Precise description of the fracture pattern including presence of an intermediate fragment in the operative report is recommended

Introduction: For a period of 7 years were treated in Emergency Hospital Pirogov 205 patients with humeral shaft fracture (HSF)–125 with interlocking nailing (ILN), 80 with AO plates, these include 55 delayed unions (DU) and nonunions (NU). Material and methods: We treated 15 DU (2–4 months), 19 NU after conservative treatment (4–12 months), 15 NU after operative treatment and 6 recalcitrant NU. 23 of the cases were men at the average age of 43.9 (18–74) and 32–women, at the average age of 64.7 (43–88). NU according to Weber-Cech were–2 hypertrophic, 18 olygotrophic and 20 atrophic, as 7 of them were infected. The initial trauma in 14 cases was high energy. The most common predisposing factors at DU are: poor bone contact–distraction 11 cases, soft tissue interposition 8 cases. At NU after conservative treatment: soft tissue interposition 13 cases and inadequate vascularity–severe injury 6 cases, and at NU after operative treatment: mechanical instability–inadequate fixation 18 cases and excessive soft tissue striping 11 cases. The usual contributing factors are: metabolic bone disease 23 cases; obesity 18 cases; poor functional level 14 cases; smoking 14 cases; advanced age 11 cases. Osteosynthesis with AO plate were 23 cases and the remaining 32–interlocking nails. Bone grafting was done in 23 cases, decortications in 12 cases, and channel reaming–in 20 cases. Results: All the cases that were treated with AO plates consolidated for the average period of 103 days (70–150) and the cases with interlocking nails (with the exception of 3–9%) for the average period of 108 days (160–240). As post-operative complications we had 6 (26%) cases of iatrogenic neurological injury with plate ostheosynthesis, 3 (10%) cases of shoulder impingements with ILN, one case of shaft fracture and infection in both methods. The patients were followed for minimum 12 months after bone union–clinical and X-ray examinations (12–60) months. We rated the final functional result according to Rommens score: excellent–29, very good–13, good–8, satisfactory–2, bad–3. Conclusion: We think that DU are more appropriate for interlocking nailing. The cases that NU are a result of unsuccessful conservative treatment, because intramedullary channel was obstructed, is better to be treated by ostheosynthesis with plate. And the contrary–it is suitable to replace ostheosynthesis with AO plate with interlocking nails after extraction of the implants in addition to bone grafting

Several recent studies have shown an increased incidence of symptomatic non-unions and malunions after non-operative treatment of displaced clavicle fractures. Our multicenter randomized control trial comparing sling treatment and plate fixation shows statistically significant improvement in patient oriented outcome measures at all time points measured over one year of follow-up. Non-operative group complications included six non-unions, one symptomatic malunion and one patient with reflex sympathetic dystrophy in thirty-four patients. Complications in the operative group included one wound dehiscence and two patients requiring plate removal in thirty-seven patients. This study supports plate fixation of acute clavicle fractures in selected cases. To compare patient oriented outcomes of non-operative and operative treatment of displaced clavicle shaft fractures. Operative fixation of displaced clavicle shaft fractures provides statistically significant improvement in functional outcome over sling treatment at one year of follow-up. This study supports operative fixation of displaced clavicle shaft fractures in selected cases. Seventy-one of one hundred and twenty patients have at least one year of follow-up. Non-operative group (N=34) consisted of twenty-four males with an average age thirty-two injuring fourteen dominant clavicles. The operative group (N= 37) consisted of thirty-three males with an average age of 34.5 years injuring twenty-one dominant clavicles. CSS and DASH scores were statistically different at all time points measured (p=0.001, p=0.021 respectively). Complications in the non-operative group included one patient with RSD, one symptomatic malunion and six patients with non-unions requiring ORIF. In the operative group, two patients experienced local plate irritation and one late wound dehiscence. Randomization was by sealed envelope. Non-operative treatment was symptomatic in a sling, while operative patients underwent ORIF. CSS, DASH and SF-36 scores were collected at six weeks, three months, six months and twelve months. Statistical analysis was completed by repeated measures multivariate analysis using SPSS. Recent studies have shown a higher incidence of symptomatic malunions and non-unions after sling treatment. Currently, sling treatment is standard of care for these fractures. Our study shows statistically signifi-cant improvement in functional outcome with operative treatment with few complications. This study supports operative treatment of displaced clavicle shaft fractures in selected cases. Funding: OTA, Zimmer Inc. Please contact author for graphs and diagrams

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

INTRODUCTION. The purpose of this study was to determine the rate of complications and re-operations after operative treatment of peri-prosthetic femur fractures sustained within 90 days following primary total hip arthroplasty (THA). METHODS. 4,433 patients (5,196 consecutive primary THAs) over 10 years at a single institution were retrospectively reviewed. Thirty-five (0.67%) peri-prosthetic fractures that were treated operatively in 32 patients were identified and classified using the Vancouver Classification. There were 9 patients with a type Ag fracture, 2 patients with a type B1 fracture, 17 patients with a type B2 fracture, 1 patient with a type B3 fracture, and 3 patients with a concomitant type Ag and B2 fracture. Eleven (34%) patients were treated with isolated ORIF: greater trochanter (9) or femoral shaft (2). Twenty-one (66%) were treated with femoral revision combined with (14) or without (7) attempted fracture fragment reduction; a diaphseal engaging stem was utilized in all revisions. One patient was lost to follow-up leaving 31 patients for evaluation. RESULTS. Nineteen (61%) patients sustained twenty-two major complications including non-union of the greater trochanter in 10 of the 12 Ag fractures, three Brooker grade 3 heterotopic ossification (10%), non-unions of both B-1 fractures (6%), two deep infections (6%), one stem subsidence that required repeat revision (3%), one greater trochanteric fracture with instability (3%), one non-union of an extended trochanteric osteotomy, one hematoma (3%) and one peroneal nerve palsy (3%). Seven patients (23%) required a second operative procedure for management of a complication and one patient required a third operation. CONCLUSIONS. Operative treatment of acute post-operative periprosthetic fractures is associated with a high rate of major complications (61%) and re-operation (23%). Operative treatment of acute post-operative fractures of the greater trochanter was associated with non-union in 10 of 12 cases (83%)

Aims: True vertical talus isnÔt to be treated successfully by conservative means alone. Untreated deformities may lead to unability of walking. The aim of the study was to evaluate the outcome of the operation described by Duckworth and Tachdjian in our patients. Methods: During 1975 until 2001 71 feet in 43 patients were operated on. The way of operation was described by Duckworth and Tachdjian. The mean age at the time of operation was þve years. The collectiv consists from 24 boys and 19 girls. Characteristics of the operation were arthrolysis and reposition of the talonavicular joint, lengthening of the achilles tendon and transposition of the anterior and posterior tibial tendon. The results were evaluated prae and postoperative by the Walker-Score and by an adittional questionare. Results: All in all 51 feet of 30 patients could be examined by clinical investigation and radiographs. The follow up was eigth years postoperative in mean. Fourteen obstacles were counted. Ten feet had addittional operative treatment later on. The evaluation by the Walker-Score counted a very good result in 13 feet, a goog in 22, an average in 13 and a poor result in three feet. From the questionaire 16 patients were very content, 36 content, 6 little content and three discontented. Conclusion: the results correlate in the procentual distribution with those described by Duckworth (n=19). Idiopathic deformities reached a higher score (14,6). Unfortunately the patients were presented to the surgeon late so that an early intercention was prevented. One may conclude that early intervention would result in a better outcome

Purpose of the study: Congenital dislocation of the patella is a very rare condition. The pathology is inconsistent and treatment modalities are unclear. The aim of the study was to show the results of operative treatment of congenital dislocation of the patella. Material and methods: 9 knee joints in 7 patients with congenital dislocation of the patella have been treated between 1989 and 1999. Additional diagnoses were Rubinstein-Taybe syndrome, Larsen syndrome, pteryg-ium syndrome and cerebral palsy in 1 patient each. The age at the time of surgery was 8.9 years on average (between 4.3 and 14.8 years). In 6 knees primary treatment was a medial shifting of the quadriceps muscle according to Stanisavljevic, in the other 3 a combination of lateral release according to Green, proximal quadriceps realignment according to Insall and either medial displacement of the tibial tuberosity according to Elmslie or a duplication of the patellar tendon according to Goldthwait had been done. Results: The follow-up time was 6.4 years on average (between 2 and 12.5 years). 4 of 9 patellae remained stable after 1 operation, 3 remained stable after 2 operations and 2 remained unstable. 4 of the 9 knees were symptomatic at the time of follow-up. All patients were able to walk and to run and all had full extension. Apart from recurrence there were no major complications. Conclusions: Permanent dislocation of the patella reduces the extension force of the quadriceps muscle significantly. Medial shifting of the quadriceps muscle according to Stanisavljevic gives the best chance to reduce the patella permanently. Postoperative taping, splinting and muscle-exercises are often necessary to get a stable situation

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

From 1998–2000 inclusive, we treated 155 acute, non-pathological fractures of the clavicle in adults. We reviewed 134, of which 95 were involving the middle third. The average time of follow-up was 24 months (range 9–33). Aim of this retrospective study was to review the results of operative versus conservative treatment in a view to create a standard protocol for these fractures management. Men accounted 67 the average age being 26.8 (range 15–83) and 28 were women with average age 36.8 (range 23–91). We operated on 23 patients: 3 due to neurological symptoms of C6 nerve root irritation, 4 due to a symptomatic non-union, 10 due to severe displacement and comminution with pressure on the overlying skin and 6 due to their request in a view to earlier return to activity as they were skilled athletes. All fractures healed within 6–14 weeks, and return to normal activity level was 8 weeks on average ( range 2–12). A 3.5mm DCP plate was used in all cases. We treated conservatively 76 patients. Non-union was encountered in 4 (4.2%) and was symptomatic in all of them so they were fixed with a 3.5mm DCP plate and bone grafted. The healing rate was 8–20 weeks, and return to pre injury activity level was 16 weeks on average (14–24). Unsatisfactory results reported from 23 patients, 21 of who were treated conservatively (27.6%) and only 2 operatively (8.7%). In the group of patients treated conservatively initial shortening was similar to the final and when 14mm or more was strongly associated with poor results. In the group treated operatively no significant shortening was found. We recommend young, active patients should be given the option of operative treatment in a view to earlier return to activities with a possible better clinical outcome

Introduction: Hip pain in young adults can be associated with radiographic finding of acetabular labral tears in magnetic resonance arthrography. Acetabular labral tears can occur in dysplastic hips and in arthrotic hips as well, but often no comobidity is found. Up to now there is no prospective study published following patients with magnetic resonance arthrography verified acetabular labral tears over time and re-evaluating them with MR years later. There is also no stage related therapy published according to labral damage. The aim of this study was to follow 100 MRI verified acetabular labral tears for four years. Material and methods: Study design was prospective, observers were blinded. At primary investigation 36 clinical and 30 radiological parameters were recorded. At follow up these factors were recorded again and additionally SF36 and Harris Hip score were recorded. Results: 100 patients with average age 42 were included. 91% of all patients could be followed for over 48 months. 55 operations were performed in 50 patients . 20 patients showed concomitant developmental dysplasia of the hip, 16 patients arthrosis, 40 patients both and 15 patients had a labral lesion alone. The last group of patients never required any operation. 28 patients had a labral lesion grade I, 29 grade II, 34 grade III. Patients with grade III lesions had a significantly lower HHS at the first examination. At follow up between all groups of patients no difference regarding any clinical parameter was found. Operations were only necessary if comorbidity (dysplasia or arthrosis) was found. No single radiologic or clinical parameter could predict operation. Nine of thirteen labral surgeries were revised (triple osteotomies or THR). No correlation between severity of labral lesion at first MRI and any parameter at follow up could be found. Conclusion: If no comorbidity was found an acetabular labral tear alone never needed operative treatment. Although there exist a series of different operative treatment opportunities in meniscal/glenoid labrum surgery , we could not find the need for surgical intervention if the acetabular labral tear occurs alone. We therefore recommend physiotherapy and non – operative treatment for these patients

Introduction: Thanks to early ultrasound diagnosis of DDH the number of late diagnosed cases decreased in the last ten years. The surgical intervention because of dislocated hip is also reduced to the few cases a year. We still however have in our practice patients after operative treatment of DDH. One of the methods used for proper hip reduction is transiliacal pelvic osteotomy described by Dega. The aim of this study is to evaluate the late results of one stage procedure with Dega transiliacal pelvic osteotomy in the treatment of DDH with dislocation. Material and Methods: In our Institution 256 dislocated hips were treated surgically by means of open hip reduction, femoral directional osteotomy and Dega’s transiliacal osteotomy. From this group 102 patients (91 female and 11 male), presented 144 operated hips were seen for the final follow-up. The left hip was affected in 45 cases, right in 17, and bilateral in 41 patients. The mean age at the surgery was 23,5 months. Mean follow-up was 19.8 years (minimum 15 years after surgery). Patients were evaluated clinically (Barrett modification of McKay classification) and radiologically using Severin classification. All radiograms from whole period of treatment were collected and evaluated. Results: In 90 hips the final result was classify as very good (57%), good in 36 hips (23%), satisfactory in 10 hips and poor in 8 hips. Radiologically very good result (group IA) was seen in 51 hips, good in 65 hips (group IB, IIA, IIB), satisfactory in 24 hips and poor in 4 hips. It was a good correlation between clinical and radiographic classification. Conclusions : The late results after one stage hip reconstruction with Dega’s transiliacal osteotomy gives a long lasting good results and is recommended for operative treatment of DDH with dislocation