Mirels’ score predicts the likelihood of sustaining pathological fractures using pain, lesion site, size and morphology. The aim is to investigate its reproducibility, reliability and accuracy in upper limb bony metastases and validate its use in pathological fracture prediction. A retrospective cohort study of patients with upper limb metastases, referred to an Orthopaedic Trauma Centre (2013–18). Mirels’ was calculated in 32 patients; plain radiographs at presentation scored by 6 raters. Radiological aspects were scored twice by each rater, 2-weeks apart. Inter- and intra-observer reliability were calculated (Fleiss’ kappa test). Bland-Altman plots compared variances of individual score components &total Mirels’ score. Mirels’ score of ≥9 did not accurately predict lesions that would fracture (11% 5/46 vs 65.2% Mirels’ score ≤8, p<0.0001). Sensitivity was 14.3% &specificity was 72.7%. When Mirels’ cut-off was lowered to ≥7, patients were more likely to fracture (48% 22/46 versus 28% 13/46, p=0.045). Sensitivity rose to 62.9%, specificity fell to 54.6%. Kappa values for interobserver variability were 0.358 (fair, 0.288–0.429) for lesion size, 0.107 (poor, 0.02–0.193) for radiological appearance and 0.274 (fair, 0.229–0.318) for total Mirels’ score. Values for intraobserver variability were 0.716 (good, 95% CI 0.432–0.999) for lesion size, 0.427 (moderate, 95% CI 0.195–0.768) for radiological appearance and 0.580 (moderate, 0.395–0.765) for total Mirels’ score. We showed moderate to substantial agreement between &within raters using Mirels’ score on upper limb radiographs. Mirels’ has poor sensitivity &specificity predicting upper limb fractures - we recommend the cut-off score for prophylactic surgery should be lower than for lower limb lesions

Introduction. Osteochondral lesions (OCLs) of the talus are a challenging and increasingly recognized problem in chronic ankle pain. Many novel techniques exist to attempt to treat this challenging entity. Difficulties associated with treating OCLs include lesion location, size, chronicity, and problems associated with potential graft harvest sites. Matrix associated stem cell transplantation (MAST) is one such treatment described for larger lesions >15mm2 or failed alternative therapies. This cohort study describes a medium-term review of the outcomes of talar lesions treated with MAST. Methods. A review of all patients treated with MAST by a single surgeon was conducted. Preoperative radiographs, MRIs and FAOS outcome questionnaire scores were conducted. Intraoperative classification was undertaken to correlate with imaging. Postoperative outcomes included FAOS scores, return to sport, revision surgery/failure of treatment and progression to arthritis/fusion surgery. Results. 58 MAST procedures in 57 patients were identified in this cohort. The mean follow up was 5 years. There were 20 females and37males, with a mean age of 37 years (SD 9.1). 22 patients had lateral OCLS were and 35 patients had medial OCLs. Of this cohort 32patients had previous surgery and 25 had this procedure as a primary event. 15 patients had one failed previous surgery, 9 patients had two, four patients had three previous surgeries and three patients had four previous surgeries. 12 patients had corrective or realignment procedures at the time of surgery. In terms of complications 3 patients of this cohort went on to have an ankle fusion and two of these had medial malleolar metal work taken out prior to this, 5 patients had additional procedures for arthrofibrotic debridements, 1 patient had a repeat MAST procedure, 1 additional patients had removal of medial malleolar osteotomy screws for pain at the osteotomy site, there were 2 wound complications one related to the ankle and one related to pain at the iliac crest donor site. Conclusion. MAST has demonstrated positive results in lesions which prove challenging to treat, even in a “ failed microfracture” cohort. RCT still lacking in field of orthobiologics for MAST. Longer term follow up required to evaluate durability

Objective. To provide a best estimate of the average treatment effect when microfracture was chosen as the intervention of choice in patients with full-thickness cartilage defects of the knee. Design. We focussed on controlled studies which either referred to microfracture alone or in comparison with any other surgical treatment of articular cartilage of the knee. Papers including patients who had been treated by microfracture and concomitant adjuvant procedures like ACL reconstruction or meniscus repair were accepted too, whereas papers reporting on the microfracture technique combined with the implantation of a scaffold were excluded. To achieve a best estimate of the average, to be expected treatment effect we pooled pooled before–after data of study arms using microfracture. Because cartilage studies employ various scales to measure functional improvements, we standardized treatment effects using Hedges' g. To provide clinically meaningful estimates we converted the pooled summary effect back into the respective scales by multiplying the pooled effect with pooled standard deviations of each included clinical scale. Results. A systematic review of the literature revealed six papers including 200 patients with a mean age of 32 years, a mean defect size of 3 cm. 2. and a follow up period from 2 to 5 years. Four of the studies compared microfracture to autologous chondrocyte implantation and two of them to osteochondral autologous transplantation. All patients were treated by the microfracture technique as described by Steadman and by a similar rehabilitation protocol which only allowed crutch-assisted touchdown weight bearing initially. Referring to the individual studies, a comparison of the pooled estimates of Hedges' g revealed that the two papers which evaluated the youngest patients provided the highest treatment effect. On the contrary, those two papers which focussed on the largest lesions, reported the worst improvement. Finally, the remaining two papers whose patients were characterized by similar age and defect size presented comparable results. The individual standardized effect sizes were combined into an overall best estimate. Its value was 1.678, measured in units of standard deviation, with the 95% confidence interval of [1.016; 2.340] resulting in different values of the average, to be expected treatment effect when it is measured in Lysholm Score (22.1), IKDC Score (26.5) and KOOS (15.2) points. Conclusions. Our results offer a clinically intuitive estimation of the average treatment effects on common clinical scales. Compared to the preoperative situation, a significant clinical improvement can be expected for each patient. Nevertheless, the magnitudes of these treatment effects are an approximation and must be interpreted cautiously. Furthermore, we did not succeed to confirm that young age and small lesion size have a beneficial effect on the clinical outcome

Objectives. Osteochondral ankle defects (OCDs) mainly occur in a young, active population. In 63% of cases the defect is located on the medial talar dome. Arthroscopic debridement and microfracture is considered the primary treatment for defects up to 15 mm. To treat patients with a secondary OCD of the medial talar dome, a 15-mm diameter metal implant (HemiCAP ®) was developed. The set of 15 offset sizes was designed to correspond with the anatomy of various talar dome curvatures. Recently, two independent biomechanical cadaver studies were published, providing rationale for clinical use. The present study was undertaken to evaluate the clinical effectiveness and safety of the metal implantation technique for osteochondral lesions of the medial talar dome in a prospective study. Material and methods. Since October 2007, twenty patients have been treated with the implant. Four patients who did not meet the inclusion criteria and four patients who had less than one-year follow-up at the time of writing were left out of this analysis. Twelve patients are reported with one year (n=8) or two years (n=4) follow-up. All patients had had one or two earlier operations without success. On preoperative CT-scanning, the mean lesion size was 16 × 11 (range, 9–26 × 8–14) mm. Outcome measures were: Numeric Rating Scale pain (NRS) at rest and when walking, Foot Ankle Outcome Score (FAOS), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, and clinical and radiographic complications. Data are presented as median and range. The Wilcoxon signed ranks test was used to calculate p-values. Results. All patients recovered well from surgery. The NRS at rest improved from 3 (0–7) preoperatively, to 0.5 (0–4) after 1 year and 1 (0–1) after 2 years follow-up (p < 0.05). The NRS when walking was 6.5 (4–8) preoperatively, improving to 1.5 (0–5) at 1 year and 1 (0–2) at 2 years follow-up (p < 0.05). The five subscales of the FAOS improved from 14–64 preoperatively, to 53–91 after 1 year and 63–100 after 2 years (p < 0.05). The AOFAS improved from 70 (42–75) before surgery to 86 (58–100) at 1 year, and 89 (82–90) at 2 years follow-up (p < 0.05). There were no clinical or radiographic complications. Conclusion. The metallic implantation technique appears to be a promising treatment for secondary OCDs of the talus, but more patients and longer follow-up are necessary to draw firm conclusions