To determine the relationship between advancing months from ACL rupture and the incidence of intra-articular meniscal and chondral damage. From a prospectively collected database 5086 patients undergoing primary ACL reconstruction, using hamstring graft, carried out between January 2000 and August 2010 were identified. Data collected included the interval between injury and surgery, type and location of meniscal tears (requiring meniscectomy) and location and severity of chondral damage (ICRS grading system). Patients were grouped according to time interval and age. The median time from ACL injury to ACL reconstruction was 3 months (range 0.25 to 480). Overall, an increasing incidence of medial meniscal injury and chondral damage occurred with advancing chronicity of ACL deficiency. The incidence of medial meniscal injury requiring meniscectomy increased from 18% of patients undergoing ACL reconstruction within 4 months of injury to 59% of patients if ACL reconstruction was delayed more than 12 months (p<0.001). The incidence of lateral meniscal tears did not increase significantly over time. The increasing incidence of secondary pathology with advancing chronicity was more pronounced in the younger age groups. The risk of a medial meniscal tear requiring resection was significantly less if surgery was performed before 5 months in the <17 years group (Odds Ratio 2) and 17–30 years group (OR 1.9), but less so in the 31–50 years group (OR 1.5) and >50 years group (OR 1.5). Advancing age was associated with a greater incidence of chondral damage and medial meniscal injury, but not lateral meniscal injury. Males had a greater incidence of lateral meniscal tears (34% vs. 20%), but not medial (28% vs. 25%) or chondral damage (35% vs. 36%), compared to females. The incidence of chondral damage and medial meniscal tears increases with advancing time after ACL injury. Particularly in younger patients, ACL reconstruction should be performed within 4 months of ACL injury in order to minimise the risk of irreversible damage to meniscal and chondral structures

Patients using a neutral rotation brace post proximal humerus fracture fixation have improved functional outcome and external rotation of the shoulder compared to patients using a standard polysling. Patients who have proximal humerus fracture fixation with extramedullary plates and screws have a risk of reduced range of movement especially external rotation. Gerber et al showed that the average external rotation after fixation of proximal humeral fractures was 39 degrees in their patient cohort compared to a normal range of 80–100 degrees. This can lead to reduced function and poor patient related outcomes. Geiger et al showed that in a cohort of 28 patients, poor functional outcome was noted in 39.3% with an average Constant-Murley Score of 57.9. Current practice is to utilise a polysling holding the shoulder in internal rotation post-shoulder fixation. Patients usually wear the sling for up to 6 weeks. We believe that this increases the risk of adhesion formation with the shoulder in internal rotation in the shoulder joint. Therefore this can cause loss of external rotation in the shoulder joint. We believe that holding the shoulder in a neutral alignment, with a neutral rotation brace post-fixation, will enable an increased rate of external rotation post-operatively thus improving external rotation and functional outcome. There is currently no literature comparing the different slings used post-operatively and we believe that this study would be the first of its kind. It would have a substantial change in the way clinicians manage proximal humeral fractures and will potentially reduce the numbers of re-operations to divide adhesions or perform capsular releases. Secondary benefits include a potential earlier return to full function and work and improved patient satisfaction. Study proposal: Prospective Randomised Controlled Trial of the neutral rotation brace compared to the standard, currently used, polysling post proximal humerus fracture fixation. No blinding of either participants or clinicians. Three surgeons utilising similar fixation techniques via the deltopectoral approach and using Philos plate fixation (Synthes Ltd.). Standardised post-operative rehabilitation protocol for all patients. Follow up: clinical review and postal outcomes for 1 year. Primary outcomes: Post operative functional outcome scores (Oxford, DASH, EQL) obtained at 6 weeks, 9 weeks, 3 months and 1 year). These will be compared to scores taken pre-operatively. Secondary outcomes: Clinical review at 6 weeks, 3 months and 1 year with range of movement measurements. Radiographs also taken at 6 weeks and 3 months to assess union. Patient questionnaire at 1 year (with outcome scores) assessing patient return to work, complications and patient satisfaction. Inclusion criteria: Proximal humeral fractures requiring operative intervention with extramedullary plate fixation (i.e. fractures displaced by 1cm and/or angulated by 45 degrees or more). Age>18. Exclusion Criteria: Patients having intra-operative findings of complete Pectoralis major rupture or if operative exposure requires complete Pectoralis major tenotomy. (These patients need to be held in internal rotation with a standard polysling to allow healing of the Pectoralis major tendon)