Decision-making regarding operative versus non-operative treatment of patients with thoracolumbar burst fractures in the absence of neurological deficits is controversial, and evidence from trials is sparse. We present a systematic review and meta-analysis of randomised trials comparing operative treatment to non-operative treatment in the management of thoracolumbar burst fractures. With the assistance of a medical librarian, an electronic search of Medline Embase and Cochrane Central Register of Controlled trials was performed. Trials were included if they: were randomided, had radiologically confirmed thoracolumbar (T10-L3) burst fractures, had no neurological deficit, compared operative and non-operative management (regardless of modality used), and had participants aged 18 and over. We examined the following outcomes: pain, using a visual analogue scale (VAS), where 0=no pain and 100=worst pain; function, using the validated Roland Morris Disability Questionnaire (RMDQ); and Kyphosis (measured in degrees). Two randomised trials including 79 patients (41 operative vs. 38 non-operative) were identified. Both trials had similar quality, patient characteristics, outcome measures, rates of follow up, and times of follow up (mean=47 months). Individual patient data meta-analysis (a powerful method of meta-analysis) was performed, since data was made available by the authors. There were no between-group differences in sex, level of fracture, mechanism of injury, follow up rates or baseline pain, kyphosis and RMDQ scores, but there was a borderline difference in age (mean 44 years in operative group vs. 39 in non-operative group, p=0.046). At final follow up, there were no between group differences in VAS pain (25 in operative group vs. 22 non-operative, p=0.63), RMDQ scores (6.1 in operative group vs. 5.8 non-operative, p=0.85), or change in RMDQ scores from baseline (4.8 in operative group vs. 5.3 non-operative, p=0.70). But both kyphosis at final follow up (11 degrees vs. 16 degrees, p=0.009) and reduction in kyphosis from baseline (1.8 degrees vs. -3.3 degrees, p=0.003) were better in the operative group. Operative management of thoracolumbar burst fractures appears to improve kyphosis, but does not improve pain or function

Introduction. Clavicle fractures can cause pain and functional impairment if not managed appropriately. This paper evaluates the prevalence of clavicular fractures, estimates number of cases requiring operative treatment, whether removal of implant is a frequent necessity and compares the final functional outcome of the operative and non-operative group. Materials/Methods. Between November 2005 and November 2007 patients with clavicular fractures were eligible for participation. Patients below 18 years of age, and pathological fractures were excluded. Operative versus non-operative treatment, radiographic classification (Allman system), complications, implant removal, and functional outcome using the University of California Los Angeles (UCLA) shoulder scores were documented and analysed. Results. Out of 16,280 fractures presenting to our University Teaching Hospitals, 200 (1.23%) met the inclusion criteria. Twenty patients were lost due to natural attrition, 159 (88.3%) patients were treated non-operatively and 21 (11.7%) patients operated upon, over half for symptomatic non-union. All clavicles united post operatively. Eighty one conservatively managed undisplaced medial, middle and lateral end fractures had excellent mean UCLA shoulder scores. A statistical significance in UCLA scores (p<0.05) was noted between the operative and non-operative groups in mid shaft fractures. Under half (42.9%) required removal of metal implant sue to soft tissue irritation with complete resolution of symptoms. Conclusion. The incidence of clavicle fractures was 1.23%. A small number of patients (11.7%) required operative treatment. We recommend surgical management of symptomatic non-union and removal of metal implant for hard ware related symptoms

Purpose. There is increasing evidence that primary fixation of displaced mid-shaft fractures of the clavicle results in superior short-term outcomes when compared to traditional non-operative methods. However, the results from published studies are limited to relatively short-term (one year or less) follow-up. Accurate data of longer follow-up is important for a number of reasons, including patient prognostication, counseling and care, the design of future trials, and the economic analysis of treatment. The purpose of this paper was to examine the results of the two year follow up of patients enrolled in a previously published randomized clinical trial of operative versus non-operative treatment of displaced fractures of the clavicle. Method. Using a comprehensive and standard assessment that included DASH (Disabilities of the Arm, Shoulder and Hand) and CSS (Constant Shoulder Scores) scores, we evaluated ninety-five patients of the original cohort of one hundred and thirty-two patients at two years following their injury. Results. Statistical analysis performed on the two year follow up data revealed that DASH and CSS scores remained essentially unchanged at two years post-injury compared to one year post-injury for both operative and non-operative groups (p>0.05). Additionally, outcome scores in the operative group remained superior to the non-operative group (DASH operative 4 +/− 7 versus DASH non-operative 11 +/− 20, p<0.014, CSS operative 97 +/− 4 versus CSS non-operative 92 +/− 14, p<0.012) at two years post-injury. Conclusion. The improvement in outcome seen with primary fixation of displaced clavicle fractures persists at two years but does not differ significantly from values seen after one year of follow-up, suggesting that clinically a steady state has been reached whereby outcome is unlikely to change with time. This has clinical, economic, and research implications

Purpose. Displaced midshaft clavicular fractures are a common injury with a high occurrence rate in young, active individuals. Non-operative care has traditionally been the standard of care for such fractures, but more recent studies have suggested benefits following primary operative fixation. The purpose of this study was to review the literature on displaced midshaft clavicle fractures, identify randomized controlled trials of operative versus non-operative treatment, and pool the functional outcome and complication rates (including nonunion and symptomatic malunion), to arrive at summary estimates of these outcomes. Method. A systematic review of the literature was performed to identify studies of randomized controlled trials comparing operative versus non-operative care for displaced midshaft clavicle fractures. Meeting abstracts were also searched and included in this study. Results. Six randomized controlled trials (n=421 patients, mean Detsky score= 15.2) were identified and included. The nonunion rate was higher in the non-operative group (28/207) then it was in patients treated operatively (3/214) (p<0.001). The rate of symptomatic malunion was higher in the non-operative group (15/207) than the operative group (0/214) (p<0.001). The total complication rate was 71 complications in 214 operative cases (33%), and 93 complications in 207 non-operative cases (45%)(p=0.016). The Constant Shoulder scores (CS) and Disability of the Arm, Shoulder and Hand (DASH) scores showed marginally improved (mean 4.1 point increase in CS at one year, mean 5.8 point decrease in DASH at one year) functional values in the operative group: this difference was especially marked in the early post operative period. Conclusion. Operative treatment provided lower complication rates (especially nonunion and symptomatic malunion) and an earlier functional return compared to non-operative treatment. However, there is little evidence at present to show that the long term effects of operative intervention are significantly superior to non-operative care

Acute achilles tendon ruptures are increasing in incidence and occur in 18 per 100 000 people per year, however there remains a lack of consensus on the best treatment of acute ruptures. Randomised studies comparing operative versus non-operative treatment show operative treatment to have a significantly lower re-rupture rate, but these studies have generally used non-weight bearing casts in the non-operative group. Recent series utilizing more aggressive non-operative protocols with early weight-bearing have noted a far lower incidence of re-rupture, with rates approaching those of operative management. Weight bearing casts may also have the advantages of convenience and an earlier return to work, and the purpose of this study was to compare outcomes of traditional casts versus Bohler-iron equipped weight-bearing casts in the treatment of acute Achilles tendon ruptures. 83 patients with acute Achilles tendon ruptures were recruited from three Auckland centres over a 2 year period. Patients were randomised within one week of injury to receive either a weight-bearing cast with a Bohler iron or a traditional non weight-bearing cast. A set treatment protocol was used, with a total cast time of eight weeks. Patients underwent detailed muscle dynamometry testing at 6 months, with further follow up at 1 year and at study completion. Primary outcomes assessed were patient satisfaction, time to return to work, and overall re-rupture rates. Secondary outcomes included return to sports, ankle pain and stiffness, footwear restrictions, and patient satisfaction. There were no significant differences in patient demographics or activity levels prior to treatment. At follow up, 1 patient (2%) in the Bohler iron group and 2 patients (5%) in the non weight bearing group sustained re-ruptures (p=0.62). There was a trend toward an earlier return to work in the weight-bearing group, with 58% versus 43% returning to work within 4 weeks, but the difference was not significant. 63% of patients in the weight bearing group reported freedom from pain at 12 months compared to 51 % in the non weight bearing group. There were no statistically significant differences in Leppilahti scores, patient satisfaction, or return to sports between groups. Weight-bearing casts in the non-operative treatment of Achilles tendon ruptures appear to offer outcomes that are at least equivalent to outcomes of non-weight bearing casts. The overall rerupture rate in this study is low, supporting the continued use of initial non-operative management in the treatment of acute ruptures