There remains much debate regarding the optimal method for surgical management of patients with long head of biceps pathology. The aim of this study was to compare the outcomes of tenotomy versus tenodesis.

This systematic review and meta-analysis was registered on PROSPERO (ref: CRD42020198658). Electronic databases searched included EMBASE, Medline, PsycINFO, and Cochrane Library. Randomized controlled trials (RCTs) comparing tenotomy versus tenodesis were included. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and the Jadad score. The primary outcome included patient reported functional outcome measures pooled using standardized mean difference (SMD) and a random effects model. Secondary outcome measures included pain (visual analogue scale VAS), rate of Popeye deformity, and operative time.

860 patients from 11 RCTs (426 tenotomy vs 434 tenodesis) were included in the meta-analysis. Pooled analysis of all PROMs data demonstrated comparable outcomes between tenotomy vs tenodesis (SMD 0.14, 95% CI −0.04 to 0.32; p=0.13). Sensitivity analysis comparing RCTs involving patients with and without an intact rotator cuff did not change the primary outcome. There was no significant difference for pain (VAS). Tenodesis resulted in a lower rate of Popeye deformity (OR 0.29, 95% CI 0.19 to 0.45, p < 0.00001). Tenotomy demonstrated a shorter operative time (MD 15.21, 95% CI 1.06 to 29.36, p < 0.00001).

Aside from a lower rate of cosmetic deformity, tenodesis yielded no measurable significant benefit to tenotomy for addressing pathology in the long head of biceps. A large multi-centre clinical effectiveness randomised controlled trial is needed to provide clarity in this area.

A number of classification systems exist for posterior malleolus fractures of the ankle. The reliability of these classification systems remains unclear. The primary aim of this study was to evaluate the reliability of three commonly utilised fracture classification systems of the posterior malleolus.

60 patients across 2 hospitals sustaining an unstable ankle fracture with a posterior malleolus fragment were identified. All patients underwent radiographs and computed tomography of their injured ankle. 9 surgeons including pre-ST3 level, ST3-8 level, and consultant level applied the Haraguchi, Rammelt, and Mason & Molloy classifications to these patients, at two timepoints, at least 4 weeks apart. The order was randomised between assessments. Inter-rater reliability was assessed using Fleiss’ kappa and 95% confidence intervals (CI). Intra-rater reliability was assessed using Cohen's Kappa and standard error (SE).

Inter-rater reliability (Fleiss’ Kappa) was calculated for the Haraguchi classification as 0.522 (95% CI 0.490 – 0.553), for the Rammelt classification as 0.626 (95% CI 0.600 – 0.652), and the Mason & Molloy classification as 0.541 (95% CI 0.514 – 0.569). Intra-rater reliability (Cohen's Kappa) was 0.764 (SE 0.034) for the Haraguchi, 0.763 (SE 0.031) for the Rammelt, 0.688 (SE 0.035) for the Mason & Molloy classification.

This study reports the inter-rater and intra-rater reliability for three classification systems for posterior malleolus fractures. Based on definitions by Landis & Koch (1977), inter-rater reliability was rated as ‘moderate’ for the Haraguchi and Mason & Molloy classifications; and ‘substantial’ for the Rammelt classification. Similarly, the intra-rater reliability was rated as ‘substantial’ for all three classifications.

Introduction and Objective

Tranexamic acid (TXA) is used across surgical specialties to reduce perioperative bleeding. It has been shown to be effective in trauma, spinal surgery, and lower limb arthroplasty. The aim of this study is to investigate the clinical effectiveness of TXA in all types of shoulder surgery on bleeding and non-bleeding related outcomes.

Introduction and Objective

There remains much debate regarding the optimal method for surgical management of patients with long head of biceps pathology. The aim of this study was to compare the outcomes of tenotomy versus tenodesis.

Uncemented total hip arthroplasty (THA) implants have become the standard for younger patients on account of increased implant survivorship and multiple other advantages. Nevertheless, uncemented THA remains controversial in elderly patients. The evidence base for this is limited, as previous studies have compared octogenarians to a younger control group. The aim of this prospective cohort study is to evaluate the outcome of octogenarian patients undergoing uncemented THA with a control group of similarly aged patients undergoing hybrid THA with a minimum 5 years follow up. Clinical outcomes including intra and postoperative complications, blood transfusion, revision rate and mortality were recorded. Radiological analysis of pre and postoperative radiograph assessed bone quality, implant fixation and any subsequent loosening. 143 patients, (mean age 86.2 yrs.) were enrolled in the study. 76 patients underwent uncemented THA and 67 underwent hybrid THA. The uncemented cohort had fewer intraoperative and postoperative complications. The uncemented cohort also had a lower transfusion rate (p=0.002). Mean hospital stay (p=0.27) was comparable between the 2 groups. Two patients underwent revision surgery in either cohort. Our study demonstrates uncemented THA is safe for the octogenarian patient and we recommend that age should be not be a barrier of choice of implant. However intraoperative assessment of bone quality should guide surgeon to the optimum decision regarding uncemented and hybrid implant.

Clostridium difficile is associated with a range of gastrointestinal disorders ranging from diarrhoea to toxic megacolon. Alteration of the normal gut flora by antibiotics is a key predisposing factor. Although antibiotic prophylaxis is routinely administered during joint replacement surgery, there has been controversy about both type and duration of prophylaxis. The primary aim of this study was to determine the incidence of C. diff associated disease (CDAD) following hip and knee replacement and to investigate potential risk factors.

A laboratory database was interrogated to identify patients developing CDAD after hip or knee replacement from January 2006 to December 2008. A database of arthroplasty patients was used to identify a control group of patients without CDAD to compare the effects of prescription of antibiotics for reasons other prophylaxis of deep infection, comorbidity and the use of gastroprotective agents.

Eight patients developed CDAD. There were 1.7 cases of CDAD per 1000 joint replacements. Patients developing CDAD were more likely to have been prescribed additional antibiotics (p=0.047). There were no differences in the use of gastroprotective agents (p=0.703). A trial of a new prophylaxis regime would require 43,198 patients in each arm to show a reduction to 1 case per 1000 procedures.

Cefuroxime based antibiotic prophylaxis is safe in patients undergoing elective joint replacement. Extremely large studies would be required to show marginal clinical benefits of new regimes. One prophylaxis policy will not suit all orthopaedic patient groups or procedures.

This study investigates the experience of one treatment centre with routine surveillance MRI following excision of sarcoma. Casenotes, MRI and histology reports for fifty-nine patients were reviewed. The primary outcome was the presence of local tumour recurrence and whether this was identified on surveillance or interval scanning. Forty-eight patients had a diagnosis of soft tissue sarcoma, the remaining 11 a primary bone tumour. Fifteen patients had local recurrence (25%). Eight were identified on surveillance scan, and the remaining 7 required interval scans.

Surveillance scanning has a role in the early detection of local recurrence of bone and soft tissue sarcoma.

Background: Complex anterior fracture-dislocations of shoulder are rare injuries and little is known about the functional outcomes following operative treatment. The aim of our study was to evaluate the functional outcomes following open reduction and internal fixation for these injuries.

Methods: Over a ten and a half year period, we studied thirty-two consecutive patients who presented to shoulder injury clinic at the Royal Infirmary of Edinburgh with an acute Type-I complex anterior fracture-dislocation of the shoulder. The average age of the 19 men and 13 women was 58 years (range 21–81 years). All patients were treated with open reduction and internal fixation and were followed up for at least two years. The functional outcomes were assessed by three scoring systems (Disabilities of the Arm, Shoulder and Hand questionnaire, the Constant questionnaire, and the Short Form-36 general health questionnaire).

Results: At two years post injury, the median DASH score was 26 points and the median Constant score was 83.5 points. The range of motion of the shoulder joint showed significant improvement throughout the two year period and degree of forward flexion and abduction continued to show significant improvement at five years. At two years, the mean forward flexion was 162°, mean extension was 152°, mean internal rotation was 109° and mean external rotation was 73°. All but one patient returned to their job at two years.

Conclusions: Type I complex anterior fracture-dislocations of the shoulder are rare and occur in the middle age and elderly group of population. Following open reduction and internal fixation, the functional outcomes have been shown to be satisfactory. We recommend that open reduction and internal fixation should be the first choice of treatment in Type-I complex anterior fracture-dislocation of shoulder.

Antibiotic prophylaxis is routinely administered during joint replacement surgery and may predispose patients to Clostridium difficile-associated disease (CDAD). The primary aim of this study was to determine the incidence of this following joint replacement, using a cefuroxime-based regimen. Patients developing CDAD were compared with a control group of patients without CDAD. The incidence of the former was 1.7 per 1000 primary joint replacements. Those patients prescribed additional antibiotics had a higher incidence of CDAD (p = 0.047), but there was no difference between the two groups in relation to the use of gastroprotective agents (p = 0.703). A trial of a new prophylaxis regimen would require 43 198 patients in each arm to show a reduction of one case per 1000 procedures. Cefuroxime-based antibiotic prophylaxis is safe in patients undergoing primary elective joint replacement.

Introduction: We conducted a prospective study on 29 patients comparing the medium-term outcome between intramedullary nail fixation and plate fixation in paediatric forearm fractures.

Materials and Methods: The criteria were patients who had a nail (10) or plate fixation (19) for a single or both bones forearm fracture between 2004 and 2006. All these patients were recalled following ethical approval for assessment of their grip strength using a hand dynamometer, forearm and elbow range of movements, scar assessment, POSNA outcome questionnaire and new radiographic views of the forearms.

Results: Mean age of 10.4 years for both groups (4–16), All fractures were caused by low velocity falls. Grip strength is reduced in 83% of patients, comparable in both groups. Elbow flexion is more reduced in the plating group but more reduction in extension in the nailing group. The reduction in forearm pronation (69% of patients) and supination (61%) were comparable in both groups. Using the ‘Manchester scar proforma’; the plating group scored worse with 14/21; nail 11/21. ‘POSNA outcome questionnaire’ score showed the nailing group had 90% excellent or good result and plating group 74%. The moderate and poor POSNA outcome (26% plate, 10% nail) were associated with pain, restricted rotation, bad scarring and difficulty lifting heavy objects. Nails were removed after bony healing but all plates were left in situ. Complete remodeling of forearm bones were seen in all radiographs in both groups. One case of non-iatrogenic ulnar nerve injury and two cases of wound infection were noted; all made full recovery.

Conclusion: The medium-term outcome at 2.5 years following either fixation method is generally comparable and good. The obvious differences were; a higher (better) POSNA score in the nailing group, larger scar formation in plating, elbow extension restriction in nailing and elbow flexion restriction in plating group. Factors that were comparable were grip strength, forearm rotation and radiographic remodeling and outcome.

Introduction: Local recurrence of tumour following definitive treatment of bone or soft tissue sarcoma is a predictor of increased morbidity. Early detection of local recurrence may affect outcome. The role of magnetic resonance imaging (MRI) screening following definitive treatment is controversial. This study investigates the experience of one treatment centre with routine surveillance MRI following treatment of sarcoma.

Methods: Patients were identified from the records of the Regional Sarcoma Group. With Local Ethics Committee approval the casenotes, MRI and histology reports for sixty-five patients who had routine surveillance MRI scans following definitive treatment of sarcoma in a single treatment centre were reviewed. The minimum follow up period was 24 months. The primary outcome was the presence of local tumour recurrence and whether this was identified on surveillance or interval scanning.

Results: There were sixty-four patients identified with a bone or soft tissue sarcoma. All had undergone surveillance scanning biannually for the first year then annually. Six patients with Ewing’s sarcoma were excluded because they had not had surgical excision. Fifty-eight patients (59% men) with a bone or soft tissue sarcoma without metastasis between 1996 and 2003 were available for study. The median age at diagnosis was 53 years (range 6–78 years). Eighty three percent had a diagnosis of soft tissue sarcoma. Ten patients had a primary bone tumour. Fourteen patients had local recurrence (24%). Six were identified on surveillance scan, and the remaining eight required interval scans because of clinical suspicion of tumour recurrence. There were no statistical differences in gender, age, or tumour characteristics between those identified on surveillance or interval scans. All those detected on surveillance had intra-lesional or marginal resections.

Conclusions: Surveillance scanning has a role in the early detection of local recurrence of bone and soft tissue sarcoma. Whether this results improvements in prognosis require longer-term follow up studies.

Purpose: The purpose of this study was to determine factors predictive of tumour recurrence, or refracture, following curettage as treatment for pathological fracture of the proximal humerus through a benign bone lesion.

Methods: From a cohort of patients held on a national database the factors predictive of recurrence following surgical curettage in patients with pathological fractures through benign bone tumours of the proximal humerus were examined. Thirty nine cases were identified. The diagnosis was simple bone cyst in 27 patients (69.2%), aneurysmal bone cyst in 4 patients (10.3%), (en)chondroma in 4 patients (10.3%), giant cell tumour in 2 patients (5.1%), benign chondroblastoma in 1 patient (2.6%) and fibroma in 1 patient (2.6%). The mean age was 16.5 years and 70% were male.

Results: Most of the patients presented with a history of trauma (77%). Five patients were excluded as their fractures were not treated with surgical curettage. Twenty two patients (65%) had recurrence of the lesion or re-fracture following curettage. None of the patients in whom the fracture occurred after skeletal maturity had a recurrence. Obliteration of the lesion occurred more frequently in those with greatest initial fracture displacement on pre-operative radiographs and in those with impacted fractures. The average time to union and obliteration of the lesion was 4 months (range 1 to 13 months).

Conclusions: Factors predictive of recurrence following curettage were age under 21 years, undisplaced fractures and fractures without impaction on initial radiographs. Patients with these features should be followed up until obliteration of the lesion or skeletal maturity.

This study reports the experience of one treatment centre with routine surveillance MRI following excision of musculoskeletal sarcoma. The case notes, MRI and histology reports for 57 patients were reviewed. The primary outcome was local tumour recurrence detected on either surveillance MRI in asymptomatic patients, or interval MRI in patients with clinical concern. A total of 47 patients had a diagnosis of soft-tissue sarcoma and ten of a primary bone tumour. A total of 13 patients (22%) had local recurrence. Nine were identified on a surveillance scan, and four by interval scans. The cost of surveillance is estimated to be £4414 per recurrence detected if low-grade tumours with clear resection margins are excluded. Surveillance scanning has a role in the early detection of local recurrence of bone and soft-tissue sarcoma.