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

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

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

Since 1986, we have treated displaced intra-articular fractures of the calcaneum by open reduction through a lateral approach, stable internal fixation and bone grafting. We assessed the results at a mean follow-up of 2.92 years in 44 patients, comparing them with those for 19 patients treated non-operatively. Clinical assessment used the scoring system of Crosby and Fitzgibbons (1990) and radiological measurements were made from lateral, axial and internal oblique views. The articular congruity of the subtalar joint and any arthritic changes were also assessed. We found significantly better results in the operated group with respect to pain, activity, range of movement, return to work and swelling of the hind foot. Radiologically, the operated group showed significantly better scores for articular congruity and arthritic changes. We conclude that the operative treatment of displaced intra-articular fractures of the calcaneum gives better medium-term results than conservative management

We have reviewed the early complications of 121 surgically treated closed ankle fractures; the complication rate was 30%, with 14 major and 22 minor complications. Fractures with skin blisters or abrasions had more than double the overall complication rate. Fracture-dislocations had three times as many major complications as simple fractures, and those not fixed within 24 hours had a 44% major complication rate compared to 5.3% in those operated upon as emergencies. Patients transferred from another medical facility had high complication rates, especially if they had fracture-dislocations. We conclude that operative treatment of ankle fractures must be delivered in a timely fashion, especially in severe fractures. We would caution against the practice of transferring patients with serious ankle fractures before completion of definitive care

Aims

The aim of this study was to utilize a national paediatric inpatient database to determine whether obesity influences the operative management and inpatient outcomes of paediatric limb fractures.

Aims. To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years. Methods. A total of 100 patients were randomized in this non-inferiority trial, comparing cast immobilization with operation with a volar locking plate. Patients with displaced AO/OTA A and C fractures were eligible if one of the following were found after initial closed reduction: 1) dorsal angulation > 10°; 2) ulnar variance > 3 mm; or 3) intra-articular step-off > 2 mm. Primary outcome measure was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) after 12 months. Secondary outcome measures were the Patient-Rated Wrist and Hand Evaluation (PRWHE), EuroQol-5 dimensions 5-level questionnaire (EQ-5D-5L), range of motion (ROM), grip strength, “satisfaction with wrist function” (score 0 to 10), and complications. Results. In all, 89 women and 11 men were included. Mean age was 74 years (65 to 91). Nonoperative treatment was non-inferior to operation with a five-point difference in median QuickDASH after 12 months (p = 0.206). After three and six months QuickDASH favoured the operative group (p = 0.010 and 0.030). Median values for PRWHE were 19 (interquartile range (IRQ) 10 to 32) in the operative group versus ten (IQR 1 to 31) in the nonoperative group at three months (p = 0.064), nine (IQR 2 to 20) versus five (IQR 0 to 13) (p = 0.020) at six months, and two (IQR 0 to 12) versus zero (IQR 0 to 8) (p = 0.019) after 12 months. Range of motion was similar between the groups. The EQ-5D-5L index score was better (mean difference 0.07) in the operative group at three and 12 months (p = 0.008 and 0.020). The complication rate was similar (p = 0.220). The operated patients were more satisfied with wrist function (median 8 (IQR 6 to 9) vs 6 (IQR 5 to 7) at three months, p = 0.002; 9 (IQR 7 to 9) vs 8 (IQR 6 to 8) at six months, p = 0.002; and 10 (IQR 8 to 10) vs 8 (IQR 7 to 9) at 12 months, p < 0.001). Conclusion. Nonoperative treatment was non-inferior to operative treatment based on QuickDASH after one year. Patients in the operative group had a faster recovery and were more satisfied with wrist function. Results from previous trials comparing operative and nonoperative treatment for displaced distal radius fractures in the elderly vary between favouring the operative group and showing similar results between the treatments. This randomized trial suggests that most elderly patients may be treated nonoperatively. Cite this article: Bone Joint J 2021;103-B(2):247–255

This retrospective cohort study was conducted to investigate whether operative treatment of patients with a pertrochanteric femoral fracture outside working hours is associated with an increased risk of complications and higher mortality. During the study period 165 patients were operated on outside working hours and 123 were operated on during working hours (08.00 to 17.00). There was no difference in the rate of early complications (outside working hours 33% versus working hours 33%, p = 0.91) or total complications during follow-up (outside working hours 40% versus working hours 41%, p = 0.91). Both in-hospital mortality (outside working hours 12% versus working hours 11%, p = 0.97) and mortality after one year (outside working hours 29% versus working hours 27%, p = 0.67) were comparable. Adjustment for possible confounders by multivariate logistic regression analysis revealed no increased risk of complications when patients were operated on outside working hours. On the basis of these data, there is no medical reason to postpone operative reduction and fixation in patients with a proximal femoral fracture until working hours

Both conservative and operative forms of treatment have been recommended for patients with a ‘floating shoulder’. We compared the results of conservative and operative treatment in 25 patients with this injury and investigated the use of the glenopolar angle (GPA) as an indicator of the functional outcome. A total of 13 patients (ten male and three female; mean age 32.5 years (24.7 to 40.4)) were treated conservatively and 12 patients (ten male and two female; mean age 33.67 years (24.6 to 42.7)) were treated operatively by fixation of the clavicular fracture alone. Outcome was assessed using the Herscovici score, which was also related to changes in the GPA at one year post-operatively. The mean Herscovici score was significantly better three months and two years after the injury in the operative group (p < 0.001 and p = 0.003, respectively). There was a negative correlation between the change in GPA and the Herscovici score at two years follow-up in both the conservative and operative groups, but neither were statistically significant (r = -0.295 and r = -0.19, respectively). There was a significant difference between the pre- and post-operative GPA in the operative group (p = 0.017). When compared with conservative treatment, fixation of the clavicle alone gives better results in the treatment of patients with a floating shoulder. The GPA changes significantly with fixation of clavicle alone but there is no significant correlation between the pre-injury GPA and the final clinical outcome in these patients. Cite this article: Bone Joint J 2013;95-B:815–19

Linburg-Comstock syndrome is characterised by an anomalous tendon slip from the flexor pollicis longus to the flexor digitorum profundus, usually of the index finger. An incidence as high as 60% to 70% has been reported. Post-traumatic inflammation of inter-tendinous connections between the flexor pollicis longus and flexor digitorum profundus, usually of the index finger, may cause unexplained chronic pain in the distal forearm. A total of 11 patients (eight females, three males), mean age 29.1 years (14 to 47) with a clinical diagnosis of Linburg-Comstock syndrome underwent surgical release of the inter-tendinous connection. The mean follow-up was for 27 months (2 to 48).

Ten patients reported excellent relief of pain in the forearm, with independent flexion of flexor pollicis longus and flexor digitorum profundus to the index finger. Surgical release was an effective treatment for the Linburg-Comstock syndrome in this series.

The aim of this study was to investigate the epidemiology of fractures of the distal radius in the Swedish population and to review the methods used to treat them between 2005 and 2010.

The study population consisted of every patient in Sweden who was diagnosed with a fracture of the wrist between 1 January 2005 and 31 December 2010. There were 177 893 fractures of the distal radius. The incidence rate in the total population was 32 per 10 000 person-years. The mean age of the patients was 44 years (0 to 104). The proportion of fractures treated operatively increased from 16% in 2005 to 20% in 2010. The incidence rate for plate fixation in the adult population increased 3.61 fold. The incidence rate for external fixation decreased by 67%. The change was greatest in the 50 years to 74 years age group.

In Sweden, there is an increasing tendency to operate on fractures of the distal radius. The previously reported increase in the use of plating is confirmed: it has increased more than threefold over a five-year period.

Cite this article: Bone Joint J 2014;96-B:963–9.

We report a retrospective study of 54 acetabular fractures treated by open reduction and internal fixation, with an average follow-up of 9.6 years (3 to 17). Reduction leaving displacement of less than or equal to 2 mm was achieved in 36 hips (67%); good or excellent functional results were obtained in 33 patients (61%). Early complications requiring re-operation included postoperative loss of reduction in one case and an intra-articular screw in another. Arthrodesis or total hip arthroplasty had been performed in 10 patients (19%) who had late symptomatic degenerative changes. Failure to obtain accurate reduction was the most important factor leading to a poor result, but heterotopic calcification caused poor results in seven patients, five of whom had had an anatomical reduction.

The conservative management of chronic calcaneal paratenonitis is time-consuming and often unsatisfactory. A new, safe and simple technique is described. The crural fascia on both sides of the tendon is incised and left open, adhesions around the tendon are trimmed away, the strongly hypertrophied portions of the paratenon are removed and mobilisation is begun immediately after operation. Between 1961 and 1978 201 such operations were performed on 182 patients 62 of whom were top-ranking Finnish athletes. Only five patients were not athletes. The results, including early return to full activity, were excellent in 169, good in 25 and poor in seven cases. After operation one of the patients gained an Olympic gold medal; others have attained international prominence.

Subluxation of the hip is common in patients with intermediate spinal muscular atrophy. This retrospective study aimed to investigate the influence of surgery on pain and function, as well as the natural history of subluxed hips which were treated conservatively. Thirty patients were assessed clinically and radiologically. Of the nine who underwent surgery only one reported satisfaction and four had recurrent subluxation. Of the 21 patients who had no surgery, 18 had subluxation at the latest follow-up, but only one reported pain in the hip. We conclude that surgery for subluxation of the hip in these patients is not justified.

We treated 49 patients at an average age of 80 years (75 to 90) with distal mostly intraarticular humeral fractures by open reduction. There were 8 class A, 13 class B and 28 class C fractures on Muller's classification. The patients were reviewed at a postoperative average of 18 months. The patients' assessment of the result was very good in 31%, good in 49%, fair in 15% and poor in 5%. The flexion-extension range was very good in 41%, good in 44% and fair in 15%. The incidence of implant failure, pseudarthrosis of the olecranon osteotomy and ulnar nerve lesion was no higher in these elderly patients than in younger patients. Old age is not a contraindication to open reduction and internal fixation; it is important to restore full function.

Our study was designed to compare the effect of indometacin with that of a placebo in reducing the incidence of heterotopic ossification in a prospective, randomised trial. A total of 121 patients with displaced fractures of the acetabulum treated by operation through a Kocher-Langenbeck approach was randomised to receive either indometacin (75 mg) sustained release, or a placebo once daily for six weeks. The extent of heterotopic ossification was evaluated on plain radiographs three months after operation. Significant ossification of Brooker grade III to IV occurred in nine of 59 patients (15.2%) in the indometacin group and 12 of 62 (19.4%) receiving the placebo.

We were unable to demonstrate a statistically significant reduction in the incidence of severe heterotopic ossification with the use of indometacin when compared with a placebo (p = 0.722). Based on these results we cannot recommend the routine use of indometacin for prophylaxis against heterotopic ossification after isolated fractures of the acetabulum.

A 30-year-old man presented with pain and limitation of movement of the right hip. The symptoms had failed to respond to conservative treatment. Radiographs and CT scans revealed evidence of impingement between the femoral head-neck junction and an abnormally large anterior inferior iliac spine. Resection of the hypertrophic anterior inferior iliac spine was performed which produced full painless restoration of function of the hip.

Hypertrophy of the anterior inferior iliac spine as a cause of femoro-acetabular impingement has not previously been described.

We report a prospective study of 55 patients with acute primary patellar dislocation, all treated by operation and followed up for at least two years. Diagnosis was based on the history of a lateral displacement, with medial tenderness and a positive apprehension test; redislocations were excluded. Before operation, the difference in lateral shift on skyline views of the injured and control patellae was highly significant. At operation, rupture of the medial retinaculum of the patella was seen in all but one case. There were medial marginal fractures of the patella in 23 cases. Subjective results of the operation were excellent or good in 44 of the 55 at two years with a redislocation rate of only 9%. Most patients were able to return to the same level of sporting activity as before the injury.

A total of 67 patients with 94 resistant club feet were treated operatively as soon after birth as all other postnatal problems could be excluded, the mean age of the patients being 12 days. No treatment was attempted before operation. The results, after a follow-up period of a minimum of two years (mean 4.4 years) are comparable with the best published results. This method of treatment has many advantages but cannot be recommended for general use without reservations.

The results of 63 operative repairs of chronic tears of the rotator cuff in 61 patients are reviewed retrospectively; the mean follow-up was 32.7 months. Fifty-four patients presented with symptoms of persistent pain and seven patients with gross loss of movement. All the patients had failed to respond to conservative treatment. Results were assessed in terms of relief of pain, restoration of movement, the patients' ability to return to work and whether they were satisfied with the results. Overall, a good result in terms of relief of pain was achieved in 40 shoulders. In 31 shoulders (30 with pain and one without pain) the operation included particular measures to decompress the subacromial space; 26 of the patients achieved relief of pain which was significantly better than in those patients whose operation did not include a decompression. The complications and failures are discussed. It is suggested that operative repair of the chronically torn rotator cuff of the shoulder is a worthwhile operation and that the operation should include an adequate decompression of the subacromial space.

Many orthopaedic surgeons believe that obese patients have a higher rate of peri-operative complications and a worse functional outcome than non-obese patients. There is, however, inconsistency in the literature supporting this notion.

This study was performed to evaluate the effect of body mass index (BMI) on injury characteristics, the incidence of complications, and the functional outcome after the operative management of unstable ankle fractures.

We retrospectively reviewed 279 patients (99 obese (BMI ≥ 30) and 180 non-obese (BMI < 30) patients who underwent surgical fixation of an unstable fracture of the ankle. We found that obese patients had a higher number of medical co-morbidities, and more Orthopaedic Trauma Association type B and C fracture types than non-obese patients. At two years from the time of injury, however, the presence of obesity did not affect the incidence of complications, the time to fracture union or the level of function.

These findings suggest that obese patients should be treated in line with standard procedures, keeping in mind any known associated medical co-morbidities.

Serial serum C-reactive protein (CRP) measurements were made, for three weeks, in 42 consecutive patients with solitary tibial fractures. The CRP response was related to the treatment: lower values were observed in 27 patients treated conservatively than in 15 operated patients. Open reduction and plating resulted in a greater response than closed intramedullary nailing. The timing of the CRP response was related to the timing of the treatment: the highest values were usually recorded two days after admission or operation. The timing of the operation did not affect the degree of CRP response. Neither the site, nor the type of fracture, nor the age of the patient played any role. Awareness of these natural CRP responses after fractures may help in the diagnosis of early post-traumatic and postoperative complications, especially infections.

From 1970 to 1978, 29 patients had a unilateral operation for bilateral recurrent dislocation of the patella. We examined 21 of them at a mean of 14 years postoperatively. Eighteen of these patients had evidence of generalised joint laxity. Six of the operated knees and four of the unoperated knees still had recurrent dislocations. The operated knees were clinically worse, with a significantly higher incidence of osteoarthritis. We concluded that the operations used to treat recurrent dislocation of the patella may have had short-term benefits, but did not cure the patients in the long term.

Forty-seven patients over the age of 55 years with a displaced fracture of the ankle were entered into a prospective, randomised study in order to compare open reduction and internal fixation with closed treatment in a plaster cast; 36 were reviewed after a mean of 27 months. The outcome was assessed clinically, radiologically and functionally using the Olerud score.

The results showed that anatomical reduction was significantly less reliable (p = 0.03) and loss of reduction significantly more common (p = 0.001) in the group with closed treatment. Those managed by open reduction and internal fixation had a significantly higher functional outcome score (p = 0.03) and a significantly better range of movement of the ankle (p = 0.044) at review.

Aims

The aim of this study was to explore whether time to surgery affects functional outcome in displaced proximal humeral fractures

Over a five-year period, adult patients with marginal impaction of acetabular fractures were identified from a registry of patients who underwent acetabular reconstruction in two tertiary referral centres. Fractures were classified according to the system of Judet and Letournel. A topographic classification to describe the extent of articular impaction was used, dividing the joint surface into superior, middle and inferior thirds. Demographic information, hospitalisation and surgery-related complications, functional (EuroQol 5-D) and radiological outcome according to Matta’s criteria were recorded and analysed. In all, 60 patients (57 men, three women) with a mean age of 41 years (18 to 72) were available at a mean follow-up of 48 months (24 to 206). The quality of the reduction was ‘anatomical’ in 44 hips (73.3%) and ‘imperfect’ in 16 (26.7%). The originally achieved anatomical reduction was lost in12 patients (25.8%). Radiologically, 33 hips (55%) were graded as ‘excellent’, 11 (18.3%) as ‘good’, one (1.7%) as ‘fair’ and 15 (25%) as ‘poor’. A total of 11 further operations were required in 11 cases, of which six were total hip replacements.

Univariate linear regression analysis of the functional outcome showed that factors associated with worse pain were increasing age and an inferior location of the impaction. Elevation of the articular impaction leads to joint preservation with satisfactory overall medium-term functional results, but secondary collapse is likely to occur in some patients.

Cite this article: Bone Joint J 2013;95-B:230–8.

Aims. Proximal humeral fractures (PHFs) are common. There is increasing evidence that most of these fractures should be treated conservatively. However, recent studies have shown an increase in use of operative treatment. The aim of this study was to identify the trends in the incidence and methods of treatment of PHFs in Finland. Methods. The study included all Finnish inhabitants aged ≥ 16 years between 1997 and 2019. All records, including diagnostic codes for PHFs and all surgical procedure codes for these fractures, were identified from two national registers. Data exclusion criteria were implemented in order to identify only acute PHFs, and the operations performed to treat them. Results. During the 23-year study period, 79,676 PHFs were identified, and 14,941 operations were performed to treat them. The incidence of PHFs steadily increased. In 2019, the overall incidence was 105 per 100,000 person-years (10. 5. ). The sex-adjusted incidence for females was 147.1 per 10. 5. , and the age-adjusted incidence for patients aged ≥ 80 years was 407.1 per 10. 5. The incidence of operative treatment for PHFs rose during the first half of the study period and decreased during the second half. The use of plate osteosynthesis in particular decreased. In 2019, the incidence of operative treatment for PHFs was 13.2 per 10. 5. , with 604 operations. Conclusion. Although the incidence of PHFs is steadily increasing, particularly in elderly females, the incidence of operative treatment is now decreasing, which is in line with current literature regarding their treatment. Cite this article: Bone Joint J 2022;104-B(1):150–156

Injuries to the quadriceps muscle group are common in athletes performing high-speed running and kicking sports. The complex anatomy of the rectus femoris puts it at greatest risk of injury. There is variability in prognosis in the literature, with reinjury rates as high as 67% in the severe graded proximal tear. Studies have highlighted that athletes can reinjure after nonoperative management, and some benefit may be derived from surgical repair to restore function and return to sport (RTS). This injury is potentially career-threatening in the elite-level athlete, and we aim to highlight the key recent literature on interventions to restore strength and function to allow early RTS while reducing the risk of injury recurrence. This article reviews the optimal diagnostic strategies and classification of quadriceps injuries. We highlight the unique anatomy of each injury on MRI and the outcomes of both nonoperative and operative treatment, providing an evidence-based management framework for athletes. Cite this article: Bone Joint J 2023;105-B(12):1244–1251

Aims. This study aimed to gather insights from elbow experts using the Delphi method to evaluate the influence of patient characteristics and fracture morphology on the choice between operative and nonoperative treatment for coronoid fractures. Methods. A three-round electronic (e-)modified Delphi survey study was performed between March and December 2023. A total of 55 elbow surgeons from Asia, Australia, Europe, and North America participated, with 48 completing all questionnaires (87%). The panellists evaluated the factors identified as important in literature for treatment decision-making, using a Likert scale ranging from "strongly influences me to recommend nonoperative treatment" (1) to "strongly influences me to recommend operative treatment" (5). Factors achieving Likert scores ≤ 2.0 or ≥ 4.0 were deemed influential for treatment recommendation. Stable consensus is defined as an agreement of ≥ 80% in the second and third rounds. Results. Of 68 factors considered important in the literature for treatment choice for coronoid fractures, 18 achieved a stable consensus to be influential. Influential factors with stable consensus that advocate for operative treatment were being a professional athlete, playing overhead sports, a history of subjective dislocation or subluxation during trauma, open fracture, crepitation with range of movement, > 2 mm opening during varus stress on radiological imaging, and having an anteromedial facet or basal coronoid fracture (O’Driscoll type 2 or 3). An anterolateral coronoid tip fracture ≤ 2 mm was the only influential factor with a stable consensus that advocates for nonoperative treatment. Most disagreement existed regarding the treatment for the terrible triad injury with an anterolateral coronoid tip fracture fragment ≤ 2 mm (O’Driscoll type 1 subtype 1). Conclusion. This study gives insights into areas of consensus among surveyed elbow surgeons in choosing between operative and nonoperative management of coronoid fractures. These findings should be used in conjunction with previous patient cohort studies when discussing treatment options with patients. Cite this article: Bone Joint J 2024;106-B(10):1150–1157

Aims. This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures. Methods. This was a retrospective cohort study of patients with acute zone 2 fifth metatarsal fractures who presented to a single large, urban, academic medical centre between December 2012 and April 2022. Zone 2 was the region of the fifth metatarsal base bordered by the fourth and fifth metatarsal articulation on the oblique radiograph. The proportion of patients allowed to bear weight as tolerated immediately after injury was compared between patients treated by orthopaedic surgeons and podiatrists. The effects of unrestricted weightbearing and foot and/or ankle immobilization on clinical healing were assessed. A total of 487 patients with zone 2 fractures were included (mean age 53.5 years (SD 16.9), mean BMI 27.2 kg/m. 2. (SD 6.0)) with a mean follow-up duration of 2.57 years (SD 2.64). Results. Overall, 281 patients (57.7%) were treated by orthopaedic surgeons, and 206 patients (42.3%) by podiatrists. When controlling for age, sex, and time between symptom onset and presentation, the likelihood of undergoing operative treatment was significantly greater when treated by a podiatrist (odds ratio (OR) 2.9 (95% CI 1.2 to 8.2); p = 0.029). A greater proportion of patients treated by orthopaedic surgeons were allowed to immediately bear weight on the injured foot (70.9% (178/251) vs 47.3% (71/150); p < 0.001). Patients treated by podiatrists were immobilized for significantly longer (mean 8.4 weeks (SD 5.7) vs 6.8 weeks (SD 4.3); p = 0.002) and experienced a significantly longer mean time to clinical healing (12.1 (SD 10.6) vs 9.0 weeks (SD 7.3), p = 0.003). Conclusion. Although there was considerable heterogeneity among zone 2 fracture management, orthopaedic surgeons were less likely to treat patients operatively and more likely to allow early full weightbearing compared to podiatrists. Cite this article: Bone Joint J 2024;106-B(9):942–948

Aims. There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures. Methods. A systematic review of seven databases was performed from the dates of their inception until the end of March 2021 to identify eligible RCTs. Reference lists of the included studies were screened. No language restrictions were applied. The primary outcome was the patient-reported outcome measure of wrist function at 12 months after injury. A meta-analysis was performed for function, pain, range of motion, grip strength, and union. Complications were reported narratively. Results. Seven RCTs were included. There was no significant difference in function between the groups at 12 months (Hedges’ g 0.15 (95% confidence interval -0.02 to 0.32); p = 0.082). The complication rate was higher in the operative group and involved more serious complications. Conclusion. We found no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively. The complication rate was higher with operative treatment. Cite this article: Bone Joint J 2022;104-B(8):953–962

Aims. Heterotopic ossification (HO) is a potentially devastating complication of the surgical treatment of a proximal humeral fracture. The literature on the rate and risk factors for the development of HO under these circumstances is lacking. The aim of this study was to determine the incidence and risk factors for the development of HO in these patients. Methods. A retrospective analysis of 170 patients who underwent operative treatment for a proximal humeral fracture between 2005 and 2016, in a single institution, was undertaken. The mean follow-up was 18.2 months (1.5 to 140). The presence of HO was identified on follow-up radiographs. Results. The incidence of HO was 15% (n = 26). Our multivariate model revealed that male sex (odds ratio (OR) 3.57, 95% confidence interval (CI) 1.30 to 9.80 compared to female) and dislocation as the initial injury (OR 5.01, 95% CI 1.31 to 19.22) were significantly associated with the formation of HO (p < 0.05) while no significant associations were seen for the age of the patient, the characteristics of the injury, or the type of operative treatment. Conclusion. This retrospective radiological study is the first to investigate the association between the method of surgical treatment for a proximal humeral fracture and the formation of HO postoperatively. We found that male sex and dislocation as the initial injury were risk factors for HO formation, whereas the method of surgical treatment, the age of the patient, and the pattern of the fracture were not predictive of HO formation. While additional studies are needed, these findings can help to identify those at an increased risk for HO formation under these circumstances. Cite this article: Bone Joint J 2020;102-B(4):539–544

The aims of this study were to determine the functional impact and financial burden of isolated and recurrent dislocation after total hip arthroplasty (THA). Our secondary goal was to determine whether there was a difference between patients who were treated non-operatively and those who were treated operatively. . We retrospectively reviewed 71 patients who had suffered dislocation of a primary THA. Their mean age was 67 years (41 to 92) and the mean follow-up was 3.8 years (2.1 to 8.2). . Because patients with recurrent dislocation were three times more likely to undergo operative treatment (p < 0.0001), they ultimately had a significantly higher mean Harris Hip Score (HHS) (p = 0.0001), lower mean Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores (p = 0.001) and a higher mean SF-12 score (p < 0.0001) than patients with a single dislocation. Likewise, those who underwent operative treatment had a higher mean HHS (p < 0.0001), lower mean WOMAC score (p < 0.0001) and a higher mean SF-12 score (p < 0.0001) than those who were treated non-operatively. Recurrent dislocation and operative treatment increased costs by 300% (£11 456; p < 0.0001) and 40% (£5217; p < 0.0001), respectively. The operative treatment of recurrent dislocation results in significantly better function than non-operative management. Moreover, the increase in costs for operative treatment is modest compared with that of non-operative measures. Cite this article: Bone Joint J 2015; 97-B:1046–9

Injuries to the hamstring muscle complex are common in athletes, accounting for between 12% and 26% of all injuries sustained during sporting activities. Acute hamstring injuries often occur during sports that involve repetitive kicking or high-speed sprinting, such as American football, soccer, rugby, and athletics. They are also common in watersports, including waterskiing and surfing. Hamstring injuries can be career-threatening in elite athletes and are associated with an estimated risk of recurrence in between 14% and 63% of patients. The variability in prognosis and treatment of the different injury patterns highlights the importance of prompt diagnosis with magnetic resonance imaging (MRI) in order to classify injuries accurately and plan the appropriate management. Low-grade hamstring injuries may be treated with nonoperative measures including pain relief, eccentric lengthening exercises, and a graduated return to sport-specific activities. Nonoperative management is associated with highly variable times for convalescence and return to a pre-injury level of sporting function. Nonoperative management of high-grade hamstring injuries is associated with poor return to baseline function, residual muscle weakness and a high-risk of recurrence. Proximal hamstring avulsion injuries, high-grade musculotendinous tears, and chronic injuries with persistent weakness or functional compromise require surgical repair to enable return to a pre-injury level of sporting function and minimize the risk of recurrent injury. This article reviews the optimal diagnostic imaging methods and common classification systems used to guide the treatment of hamstring injuries. In addition, the indications and outcomes for both nonoperative and operative treatment are analyzed to provide an evidence-based management framework for these patients. Cite this article: Bone Joint J 2020;102-B(10):1281–1288

Aims. Functional rehabilitation has become an increasingly popular treatment for Achilles tendon rupture (ATR), providing comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. Limited evidence exists on whether gap size should affect patient selection for this treatment option. The aim of this study was to assess if size of gap between ruptured tendon ends affects patient-reported outcome following ATR treated with functional rehabilitation. Methods. Analysis of prospectively collected data on all 131 patients diagnosed with ATR at Royal Berkshire Hospital, UK, from August 2016 to January 2019 and managed non-operatively was performed. Diagnosis was confirmed on all patients by dynamic ultrasound scanning and gap size measured with ankle in full plantarflexion. Functional rehabilitation using an established protocol was the preferred treatment. All non-operatively treated patients with completed Achilles Tendon Rupture Scores (ATRS) at a minimum of 12 months following injury were included. Results. In all, 82 patients with completed ATRS were included in the analysis. Their mean age was 51 years (standard deviation (SD) 14). The mean ATRS was 76 (SD 19) at a mean follow-up of 20 months (SD 11) following injury. Gap inversely affected ATRS with a Pearson’s correlation of -0.30 (p = 0.008). Mean ATRS was lower with gaps > 5 mm compared with ≤ 5 mm (73 (SD 21) vs 82 (SD 16); p = 0.031). Mean ATRS was lowest (70 (SD 23)) with gaps > 10 mm, with significant differences in perceived strength and pain. The overall re-rupture rate was two out of 131 (1.5%). Conclusion. Increasing gap size predicts lower patient-reported outcome, as measured by ATRS. Tendon gap > 5 mm may be a useful predictor in physically demanding individuals, and tendon gap > 10 mm for those with low physical demand. Further studies that control for gap size when comparing non-operative and operative treatment are required to assess if these patients may benefit from surgery, particularly when balanced against the surgical risks. Cite this article: Bone Joint J 2020;102-B(11):1535–1541

Aims. Debate continues regarding the optimum management of periprosthetic distal femoral fractures (PDFFs). This study aims to determine which operative treatment is associated with the lowest perioperative morbidity and mortality when treating low (Su type II and III) PDFFs comparing lateral locking plate fixation (LLP-ORIF) or distal femoral arthroplasty (DFA). Methods. This was a retrospective cohort study of 60 consecutive unilateral (PDFFs) of Su types II (40/60) and III (20/60) in patients aged ≥ 60 years: 33 underwent LLP-ORIF (mean age 81.3 years (SD 10.5), BMI 26.7 (SD 5.5); 29/33 female); and 27 underwent DFA (mean age 78.8 years (SD 8.3); BMI 26.7 (SD 6.6); 19/27 female). The primary outcome measure was reoperation. Secondary outcomes included perioperative complications, calculated blood loss, transfusion requirements, functional mobility status, length of acute hospital stay, discharge destination and mortality. Kaplan-Meier survival analysis was performed. Cox multivariate regression analysis was performed to identify risk factors for reoperation after LLP-ORIF. Results. Follow-up was at mean 3.8 years (1.0 to 10.4). One-year mortality was 13% (8/60). Reoperation was more common following LLP-ORIF: 7/33 versus 0/27 (p = 0.008). Five-year survival for reoperation was significantly better following DFA; 100% compared to 70.8% (95% confidence interval (CI) 51.8% to 89.8%, p = 0.006). There was no difference for the endpoint mechanical failure (including radiological loosening); ORIF 74.5% (56.3 to 92.7), and DFA 78.2% (52.3 to 100, p = 0.182). Reoperation following LLP-ORIF was independently associated with medial comminution; hazard ratio (HR) 10.7 (1.45 to 79.5, p = 0.020). Anatomical reduction was protective against reoperation; HR 0.11 (0.013 to 0.96, p = 0.046). When inadequately fixed fractures were excluded, there was no difference in five-year survival for either reoperation (p = 0.156) or mechanical failure (p = 0.453). Conclusion. Absolute reoperation rates are higher following LLP fixation of low PDFFs compared to DFA. Where LLP-ORIF was well performed with augmentation of medial comminution, there was no difference in survival compared to DFA. Though necessary in very low fractures, DFA should be used with caution in patients with greater life expectancies due to the risk of longer term aseptic loosening. Cite this article: Bone Joint J 2021;103-B(4):635–643

Children presenting with Perthes’ disease before their sixth birthday are considered to have a good prognosis. We describe 166 hips in children in this age group. The mean age at onset of the disease was 44 months (22 to 72). Mild forms (Catterall I and II) were treated conservatively and severe forms (Catterall III and IV) either conservatively or operatively. The aim of the former treatment was to restrict weight-bearing. Operative treatment consisted of innominate osteotomy and was indicated by a Conway type-B appearance on the bone scan. All the patients were followed to skeletal maturity with a mean follow-up of 11 years (8 to 15). The end results were evaluated radiologically using the classifications of Stulberg and Mose. A total of 50 hips were Catterall grade-I or grade-II, 65 Catterall grade-III and 51 Catterall grade-IV. All hips with mild disease had a good result at skeletal maturity. Of the hips with severe disease 78 (67.3%) had good (Stulberg I and II), 26 (22.4%) fair (Stulberg III) and 12 (10.3%) poor results (Stulberg IV and V). Of the Catterall grade-III hips 38 were treated conservatively of which 31 (81.6%) had a good result, six (15.8%) a fair and one (2.6%) a poor result. Operative treatment was carried out on 27 Catterall grade-III hips, of which 21 (77.8%) had a good, four (14.8%) a fair and two (7.4%) a poor result. By comparison conservative treatment of 19 Catterall grade-IV hips led to ten (52.7%) good, seven (36.8%) fair and two (10.5%) poor results. Operative treatment was carried out on 32 Catterall grade-IV hips, of which 16 (50.0%) had a good, nine (28.1%) a fair and seven (21.9%) a poor result. We confirm that the prognosis in Perthes’ disease is generally good when the age at onset is less than six years. In severe disease there is no significant difference in outcome after conservative or operative treatment (p > 0.05). Catterall grade-III hips had a better outcome according to the Stulberg and Mose criteria than Catterall grade-IV hips, regardless of the method of treatment

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The Vantage Total Ankle System is a fourth-generation low-profile fixed-bearing implant that has been available since 2016. We aimed to describe our early experience with this implant.

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The aim of this study was to investigate the association between fracture displacement and survivorship of the native hip joint without conversion to a total hip arthroplasty (THA), and to determine predictors for conversion to THA in patients treated nonoperatively for acetabular fractures.

Aims. Recent studies of nonoperatively treated displaced midshaft clavicular fractures have shown a high incidence of nonunion and unsatisfactory functional outcome. Some studies have shown superior functional results and higher rates of healing following operative treatment. The aim of this study was to compare the outcome in these patients after nonoperative management with those treated with fixation. Patients and Methods. In a multicentre, parallel randomized controlled trial, 146 adult patients with an acute displaced fracture of the midthird of the clavicle were randomized to either nonoperative treatment with a sling (71, 55 men and 16 women with a mean age of 39 years, 18 to 60) or fixation with a pre-contoured plate and locking screws (75, 64 men and 11 women with a mean age of 40 years, 18 to 60). Outcome was assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) Score, the Constant Score, and radiographical evidence of union. Patients were followed for one year. Results. A total of 60 patients in the nonoperative group and 64 in the operative group completed one-year follow-up. At three months’ follow-up, both the median DASH (1.7 vs 8.3) and median Constant scores (97 vs 90) were significantly better in the operated group (both p = 0.02). After six months and one year, there was no difference in the median DASH or Constant scores. The rate of nonunion was lower in the operative group (2 vs 11 patients, p < 0.02). Nine patients in the nonoperative group underwent surgery for nonunion. The plate was subsequently removed in 16 patients (25%). One patient had a new fracture after removal of the plate and one underwent revision surgery for failure of fixation. Conclusion. Fixation of a displaced midshaft clavicular fracture using a pre-contoured plate and locking screws results in faster functional recovery and a higher rate of union compared with nonoperative management, but the function of the shoulder is equal after six months and at one year. Cite this article: Bone Joint J 2018;100-B:1385–91

There is a disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. Anterior cruciate ligament ruptures are between two and eight times more common than in males, and females also have a higher incidence of ankle sprains, patellofemoral pain, and bone stress injuries. The sequelae of such injuries can be devastating to an athlete, resulting in time out of sport, surgery, and the early onset of osteoarthritis. It is important to identify the causes of this disparity and introduce prevention programmes to reduce the incidence of these injuries. A natural difference reflects the effect of reproductive hormones in females, which have receptors in certain musculoskeletal tissues. Relaxin increases ligamentous laxity. Oestrogen decreases the synthesis of collagen and progesterone does the opposite. Insufficient diet and intensive training can lead to menstrual irregularities, which are common in female athletes and result in injury, whereas oral contraception may have a protective effect against certain injuries. It is important for coaches, physiotherapists, nutritionists, doctors, and athletes to be aware of these issues and to implement preventive measures. This annotation explores the relationship between the menstrual cycle and orthopaedic sports injuries in pre-menopausal females, and proposes recommendations to mitigate the risk of sustaining these injuries.

Cite this article: Bone Joint J 2023;105-B(7):723–728.

Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.

Cite this article: Bone Joint J 2023;105-B(2):112–123.

In 2017, the British Society for Children’s Orthopaedic Surgery engaged the profession and all relevant stakeholders in two formal research prioritization processes. In this editorial, we describe the impact of this prioritization on funding, and how research in children’s orthopaedics, which was until very recently a largely unfunded and under-investigated area, is now flourishing. Establishing research priorities was a crucial step in this process.

Cite this article: Bone Joint J 2024;106-B(5):422–424.

Aims. Bone health assessment and the prescription of medication for secondary fracture prevention have become an integral part of the acute management of patients with hip fracture. However, there is little evidence regarding compliance with prescription guidelines and subsequent adherence to medication in this patient group. Patients and Methods. The World Hip Trauma Evaluation (WHiTE) is a multicentre, prospective cohort of hip fracture patients in NHS hospitals in England and Wales. Patients aged 60 years and older who received operative treatment for a hip fracture were eligible for inclusion in WHiTE. The prescription of bone protection medications was recorded from participants’ discharge summaries, and participant-reported use of bone protection medications was recorded at 120 days following surgery. Results. Of 5456 recruited patients with baseline data, 2853 patients (52%) were prescribed bone protection medication at discharge, of which oral bisphosphonates were the most common, 4109 patients (75%) were prescribed vitamin D or calcium, and 606 patients (11%) were not prescribed anything. Of those prescribed a bone protection medication, only 932 patients (33%) reported still taking their medication 120 days later. Conclusion. These data provide a reference for current prescription and adherence rates. Adherence with oral medication remains poor in patients with hip fracture. Cite this article: Bone Joint J 2019;101-B:1402–1407

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To analyze whether the addition of risk-based criteria to clinical examination-based selective ultrasound screening would increase the rates of early detected cases of developmental dysplasia of the hip (DDH) and decrease the rate of late detected cases.

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The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach.

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The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process.

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We aimed to compare reoperations following distal radial fractures (DRFs) managed with early fixation versus delayed fixation following initial closed reduction (CR).

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We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

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The aim of this study was to report the pooled prevalence of post-traumatic osteoarthritis (PTOA) and examine whether the risk of developing PTOA after anterior cruciate ligament (ACL) injury has decreased in recent decades.

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Periprosthetic proximal femoral fractures (PFFs) are a major complication after total hip arthroplasty (THA). Health status after PFF is not specifically investigated. The aim of this study is to evaluate the health status pattern over two years after sustaining a PFF.

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This scoping review aims to identify patient-related factors associated with a poorer outcome following total ankle arthroplasty (TAA).

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Most patients with advanced malignancy suffer bone metastases, which pose a significant challenge to orthopaedic services and burden to the health economy. This study aimed to assess adherence to the British Orthopaedic Oncology Society (BOOS)/British Orthopaedic Association (BOA) guidelines on patients with metastatic bone disease (MBD) in the UK.

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The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.

Fractures of the femoral neck in children are rare, high-energy injuries with high complication rates. Their treatment has become more interventional but evidence of the efficacy of such measures is limited. We performed a systematic review of studies examining different types of treatment and their outcomes, including avascular necrosis (AVN), nonunion, coxa vara, premature physeal closure (PPC), and Ratliff’s clinical criteria. A total of 30 studies were included, comprising 935 patients. Operative treatment and open reduction were associated with higher rates of AVN. Delbet types I and II fractures were most likely to undergo open reduction and internal fixation. Coxa vara was reduced in the operative group, whereas nonunion and PPC were not related to surgical intervention. Nonunion and coxa vara were unaffected by the method of reduction. Capsular decompression had no effect on AVN. Although surgery allows a more anatomical union, it is uncertain whether operative treatment or the type of reduction affects the rate of AVN, nonunion or PPC, because more severe fractures were operated upon more frequently. A delay in treatment beyond 24 hours was associated with a higher incidence of AVN. Cite this article: Bone Joint J 2013;95-B:135-41

Aims. To report our experience with trunnion corrosion following metal-on-polyethylene total hip arthroplasty, in particular to report the spectrum of presentation and determine the mean time to presentation. Patients and Methods. We report the presenting symptoms and signs, intraoperative findings, and early results and complications of operative treatment in nine patients with a mean age of 74 years (60 to 86). The onset of symptoms was at a mean of seven years (3 to 18) after index surgery. Results. Patients presented with a variety of symptoms including pain, limp and rash. The preoperative mean serum cobalt level was 7.1 ppb (2.2 to 12.8) and mean serum chromium level was 2.2 ppb (0.5 to 5.2). Metal artifact reduction sequence (MARS) MRI showed fluid collection and possible pseudotumour formation in five hips, fluid collection in two hips, and synovitis/debris in one hip, with no MRI in one patient. Acetabular revision was performed in three patients, six patients underwent liner and head exchange only. The postoperative metal levels decreased in all patients: mean cobalt 0.5 ppb (0 to 1.8) and mean chromium 0.9 ppb (0 to 2.6) at a mean of five months (3 to 8) postoperatively. Seven patients had good pain relief and no complications at one year. There were two major complications requiring reoperation: acute infection at six weeks, for which the patient required two-stage reimplantation; and recurrent dislocation, for which the patient was revised to a dual mobility component. Conclusion. Trunnion corrosion in metal-on-polyethylene THA has a range of presenting symptoms, and may present later than previously described. A high index of suspicion is warranted, and serum cobalt and chromium levels are recommended for diagnosis. Patients should be counselled about possible postoperative complications. Cite this article: Bone Joint J 2018;100-B:898–902

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Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England.

Aims. The aim of this retrospective multicentre study was to evaluate mid-term results of the operative treatment of Monteggia-like lesions and to determine the prognostic factors that influence the clinical and radiological outcome. Patients and Methods. A total of 46 patients (27 women and 19 men), with a mean age of 57.7 years (18 to 84) who had sustained a Monteggia-like lesion were followed up clinically and radiologically after surgical treatment. The Mayo Modified Wrist Score (MMWS), Mayo Elbow Performance Score (MEPS), Broberg and Morrey Score, and Disabilities of the Arm, Shoulder and Hand (DASH) score were used for evaluation at a mean of 65 months (27 to 111) postoperatively. All ulnar fractures were stabilized using a proximally contoured or precontoured locking compression plate. Mason type I fractures of the radial head were treated conservatively, type II fractures were treated with reconstruction, and type III fractures with arthroplasty. All Morrey type II and III fractures of the coronoid process was stabilized using lag screws. Results. Good results were found for the MMWS, with a mean of 88.4 (40 to 100). There were 29 excellent results (63%), nine good (20%), seven satisfactory (15%), and one poor (2%). Excellent results were obtained for the MEPS, with a mean of 90.7 (70 to 100): 31 excellent results (68%), 13 good (28%), and two fair (4%). Good results were also found for the functional rating index of Broberg and Morrey, with a mean score of 86.6 (57 to 100). There were 16 excellent results (35%), 22 good (48%), six fair (13%), and two poor (4%). The mean DASH score was 15.1 (0 to 55.8). Two patients had delayed wound healing; four patients had nonunion requiring bone grafting. One patient had asymptomatic loosening of the radial head prosthesis. Conclusion. Monteggia-like lesions are rare. With correct identification, classification, and understanding using CT scans followed by appropriate surgical treatment that addresses all components of the injury, good to excellent mid-term results can be achieved. Cite this article: Bone Joint J 2018;100-B:212–18

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The aim of this study was to describe the management and associated outcomes of patients sustaining a femoral hip periprosthetic fracture (PPF) in the UK population.

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The aim of this study was to explore the relationship between reason for revision total hip arthroplasty (rTHA) and outcomes in terms of patient-reported outcome measures (PROMs).

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The aim of this study was to estimate the clinical and economic burden of dislocation following primary total hip arthroplasty (THA) in England.

Aims. Rotator cuff tendinopathy has a multifactorial origin. Rejecting the mechanistic theory has also led to abandoning operative treatment at initial presentation in the first line. Physiotherapy exercise programmes are the accepted first line treatment. The aim of this study was to assess the long-term additional benefits of subacromial decompression in the treatment of rotator cuff tendinopathy. Patients and Methods. This randomised controlled trial of 140 patients (52 men, 88 women, mean age 47.1 years; 18 to 60) with rotator cuff tendinopathy extended previous work up to a maximum of 13 years. The patients were randomised into two treatment groups: arthroscopic acromioplasty and a supervised exercise treatment and a similar supervised exercise treatment alone. Self-reported pain on a visual analogue scale (VAS) was the primary outcome measure. Secondary measures were disability, working ability, pain at night, Shoulder Disability Questionnaire score and the number of painful days during the three months preceding the final assessment. Results. A total of 90 patients (64%) returned questionnaires at a mean 12 years after randomisation. On an intention-to-treat basis, both treatment groups reached statistically significant improvement compared with the initial VAS for pain, but there was no significant difference between groups. The same was true in the secondary outcome measures. Due to group changes, the results were also analysed per protocol: operated or not. No significant differences between the groups were found. Conclusion. The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term. Even though the patients who underwent operative treatment had a stronger belief in recovery, which is likely to be surgical and the effect of placebo, the exercise group obtained similar results. In the future, an optimum exercise regime should be searched for, as the most clinically and cost-effective conservative treatment for rotator cuff tendinopathy. Cite this article: Bone Joint J 2017;99-B:799–805

This study compares the cost-effectiveness of treating dorsally displaced distal radial fractures with a volar locking plate and percutaneous fixation. It was performed from the perspective of the National Health Service (NHS) using data from a single-centre randomised controlled trial. In total 130 patients (18 to 73 years of age) with a dorsally displaced distal radial fracture were randomised to treatment with either a volar locking plate (n = 66) or percutaneous fixation (n = 64). The methodology was according to National Institute for Health and Care Excellence guidance for technology appraisals. . There were no significant differences in quality of life scores between groups at any time point in the study. Both groups returned to baseline one year post-operatively. . NHS costs for the plate group were significantly higher (p < 0.001, 95% confidence interval 497 to 930). For an additional £713, fixation with a volar locking plate offered 0.0178 additional quality-adjusted life years in the year after surgery. The incremental cost-effectiveness ratio (ICER) for plate fixation relative to percutaneous fixation at list price was £40 068. When adjusting the prices of the implants for a 20% hospital discount, the ICER was £31 898. Patients who underwent plate fixation did not return to work earlier. We found no evidence to support the cost-effectiveness, from the perspective of the NHS, of fixation using a volar locking plate over percutaneous fixation for the operative treatment of a dorsally displaced radial fracture. Cite this article: Bone Joint J 2015;97-B:1264–70

Monostotic fibrous dysplasia of the proximal femur has a variable clinical course, despite its reported limited tendency to progress. We investigated the natural history and predisposing factors for progression of dysplasia in a group of 76 patients with a mean follow-up of 8.5 years (2.0 to 15.2). Of these, 31 (41%) presented with an asymptomatic incidental lesion while 45 (59%) presented with pain or a pathological fracture. A group of 23 patients (30%) underwent early operative treatment for pain (19: 25%) or pathological fracture (4: 5%). Of the 53 patients who were initially treated non-operatively, 45 (85%) remained asymptomatic but eight (15%) needed surgery because of pain or fracture. The progression-free survival of the observation group was 81% (. sd. 6.4%) at five-years follow-up. An initial presentation of pain (p < 0.001), a limp (p < 0.001), radiological evidence of microfracture (p = 0.001) and younger age (< 17 years) (p = 0.016) were significant predisposing factors for disease progression. The risk of experiencing pain or pathological fracture is considerable in monostotic fibrous dysplasia of the proximal femur. Patients presenting with pain, a limp or radiological evidence of microfracture have a high chance of needing surgical treatment. Cite this article: Bone Joint J 2014;96-B:673–6

We compared the long-term outcome in 61 patients (62 fractures) treated operatively or conservatively for an acute fracture of the carpal scaphoid. A total of 30 fractures was randomised to conservative treatment using a cast and 32 to operative treatment using a Herbert bone screw. The duration of sick leave was shorter for patients treated by operation, but this was only significant in patients with blue-collar occupations. There were no differences between the groups in respect of function, radiological healing of the fracture, or carpal arthritis after follow-up at 12 years. Those managed by operation showed radiological signs of arthritis of the scaphotrapezial joint more often, but this finding did not correlate with subjective symptoms. Operative treatment of an acute fracture of the scaphoid allows early return of function and should be regarded as an alternative to conservative treatment in patients in whom immobilisation in a cast for three months is not acceptable for reasons related to sports, social life or work

1. Published comparisons of the results of conservative and operative treatment of trochanteric fractures have been fallacious because the groups have not been strictly comparable and because all deaths during convalescence have not been included. 2. In a series of cases studied at Oxford, comparable groups have been secured by allotting alternate cases to each group. All deaths within three months of injury have been included, whether occurring in hospital or elsewhere. 3. There was no great difference in mortality or in functional results between the two groups. One type of trochanteric fracture gives poor results whatever the method of treatment. 4. The series is too small for statistical conclusions, but the results suggest that the only advantages of operative treatment are greater economy of hospital beds, and increased comfort and mobility for the patient. The latter factor is important in frail patients, who are believed to be less prone to develop non-fatal complications if treated by operation than if treated conservatively

Consecutive patients with a confirmed rupture of at least one of the lateral ligaments of the ankle were randomly assigned to receive either operative or functional treatment. They were evaluated at a median of 8 years (6 to 11). In total, 370 patients were included. Follow-up was available for 317 (86%). Fewer patients allocated to operative treatment reported residual pain compared with those who had been allocated to functional treatment (16% versus 25%, RR 0.64, CI 041 to 1.0). Fewer surgically-treated patients reported symptoms of giving way (20% versus 32%, RR 0.62, CI 0.42 to 0.92) and recurrent sprains (22% versus 34%, RR 0.66, CI 0.45 to 0.94). The anterior drawer test was less frequently positive in surgically-treated patients (30% versus 54%, RR 0.54, CI 0.41 to 0.72). The median Povacz score was significantly higher in the operative group (26 versus 22, p < 0.001). Compared with functional treatment, operative treatment gives a better long-term outcome in terms of residual pain, recurrent sprains and stability

Aims. The appropriate management for patients with a degenerative tear of the rotator cuff remains controversial, but operative treatment, particularly arthroscopic surgery, is increasingly being used. Our aim in this paper was to compare the effectiveness of arthroscopic with open repair of the rotator cuff. Patients and Methods. A total of 273 patients were recruited to a randomised comparison trial (136 to arthroscopic surgery and 137 to open surgery) from 19 teaching and general hospitals in the United Kingdom. The surgeons used their usual preferred method of repair. The Oxford Shoulder Score (OSS), two years post-operatively, was the primary outcome measure. Imaging of the shoulder was performed at one year after surgery. The trial is registered with Current Controlled Trials, ISRCTN97804283. Results. The mean OSS improved from 26.3 (standard deviation (. sd. ) 8.2) at baseline, to 41.7 (. sd. 7.9) two years post-operatively for arthroscopic surgery and from 25.0 (. sd. 8.0) to 41.5 (. sd. 7.9) for open surgery. Intention-to-treat (ITT) analysis showed no statistical difference between the groups at two years (difference in OSS score -0.76; 95% confidence interval (CI) -2.75 to 1.22; p = 0.452). The confidence interval excluded the pre-determined clinically important difference in the OSS of three points. The rate of re-tear was not significantly different between the two groups (46.4% for arthroscopic and 38.6% for open surgery; 95% CI -6.9 to 25.8; p = 0.256). Healed repairs had the most improved OSS. These findings were the same when analysed per-protocol. Conclusion. There is no evidence of difference in effectiveness between open and arthroscopic repair of rotator cuff tears. The rate of re-tear is high in both groups, for all sizes of tear and ages and this adversely affects the outcome. Cite this article: Bone Joint J 2017;99-B:107–15

We have compared three different methods of treating symptomatic non-traumatic tears of the supraspinatus tendon in patients above 55 years of age. A total of 180 shoulders (173 patients) with supraspinatus tendon tears were randomly allocated into one of three groups (each of 60 shoulders); physiotherapy (group 1), acromioplasty and physiotherapy (group 2) and rotator cuff repair, acromioplasty and physiotherapy (group 3). The Constant score was assessed and followed up by an independent observer pre-operatively and at three, six and twelve months after the intervention. Of these, 167 shoulders were available for assessment at one year (follow-up rate of 92.8%). There were 55 shoulders in group 1 (24 in males and 31 in females, mean age 65 years (55 to 79)), 57 in group 2 (29 male and 28 female, mean age 65 years (55 to 79)) and 55 shoulders in group 3 (26 male and 29 female, mean age 65 years (55 to 81)). There were no between-group differences in the Constant score at final follow-up: 74.1 (. sd. 14.2), 77.2 (. sd. 13.0) and 77.9 (. sd. 12.1) in groups 1, 2 and 3, respectively (p = 0.34). The mean change in the Constant score was 17.0, 17.5, and 19.8, respectively (p = 0.34). These results suggest that at one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition. Cite this article: Bone Joint J 2014;96-B:75–81

Aims

The patient-acceptable symptom state (PASS) is a level of wellbeing, which is measured by the patient. The aim of this study was to determine if the proportion of patients who achieved an acceptable level of function (PASS) after medial unicompartmental knee arthroplasty (UKA) was different based on the status of the anterior cruciate ligament (ACL) at the time of surgery.

The purpose of this study was to review the long-term outcomes of a previously reported prospective series of 46 type III acromioclavicular dislocations. These were treated surgically with temporary fixation of the acromioclavicular joint with wires, repair of the acromioclavicular ligaments, and overlapped suture of the deltoid and trapezius muscles. Of the 46 patients, one had died, four could not be traced, and three declined to return for follow-up, leaving 38 patients in the study. There were 36 men and two women, with a mean age at follow-up of 57.3 years (41 to 71). The mean follow-up was 24.2 years (21 to 26). Patients were evaluated using the Imatani and University of California, Los Angeles (UCLA) scoring systems. Their subjective status was assessed using the Disabilities of the Arm, Shoulder and Hand and Simple Shoulder Test questionnaires, and a visual analogue scale for patient satisfaction. The examination included radiographs of the shoulder. At a follow-up of 21 years, the results were satisfactory in 35 (92.1%) patients and unsatisfactory in three (7.9%). In total, 35 patients (92.1%) reported no pain, one slight pain, and two moderate pain. All except two patients had a full range of shoulder movement compared with the opposite side. Unsatisfactory results were the result of early redisplacement in two patients, and osteoarthritis without redisplacement in one. According to the Imatani and UCLA scores, there was no difference between the operated shoulder and the opposite shoulder (p > 0.05). Given the same situation, 35 (92.1%) patients would opt for the same surgical treatment again. Operative treatment of type III acromioclavicular joint injuries produces satisfactory long-term results

Avascular necrosis of the scaphoid following a fracture in children is rare and there is no established treatment protocol in the literature. We present two boys with nonunion and avascular necrosis of the scaphoid treated by simple immobilisation. Both cases healed with painless wrists and full movements. Our cases confirm that an ununited scaphoid fracture in children may heal with conservative treatment, even when an MRI scan suggests avascular necrosis. Unlike in adults, operative treatment need only be considered in children when conservative treatment fails

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The proportion of arthroplasties performed in the ambulatory setting has increased considerably. However, there are concerns whether same-day discharge may increase the risk of complications. The aim of this study was to compare 90-day outcomes between inpatient arthroplasties and outpatient arthroplasties performed at an ambulatory surgery centre (ASC), and determine whether there is a learning curve associated with performing athroplasties in an ASC.

We report a randomised controlled trial to examine the effectiveness and cost-effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. A total of 140 patients were randomly divided into two treatment groups: supervised exercise programme (n = 70, exercise group) and arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). The main outcome measure was self-reported pain on a visual analogue scale of 0 to 10 at 24 months, measured on the 134 patients (66 in the exercise group and 68 in the combined treatment group) for whom endpoint data were available. An intention-to-treat analysis disclosed an improvement in both groups but without statistically significant difference in outcome between the groups (p = 0.65). The combined treatment was considerably more costly. Arthroscopic acromioplasty provides no clinically important effects over a structured and supervised exercise programme alone in terms of subjective outcome or cost-effectiveness when measured at 24 months. Structured exercise treatment should be the basis for treatment of shoulder impingement syndrome, with operative treatment offered judiciously until its true merit is proven

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To assess the characteristic clinical features, management, and outcome of patients who present to orthopaedic surgeons with functional dystonia affecting the foot and ankle.

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We report the long-term outcomes of the UK Heel Fracture Trial (HeFT), a pragmatic, multicentre, two-arm, assessor-blinded, randomized controlled trial.

Controversy surrounds the most appropriate treatment method for patients with a rupture of the tendo Achillis. The aim of this study was to assess the long term rate of re-rupture following management with a non-operative functional protocol. . We report the outcome of 945 consecutive patients (949 tendons) diagnosed with a rupture of the tendo Achillis managed between 1996 and 2008. There were 255 female and 690 male patients with a mean age of 48.97 years (12 to 86). Delayed presentation was defined as establishing the diagnosis and commencing treatment more than two weeks after injury. The overall rate of re-rupture was 2.8% (27 re-ruptures), with a rate of 2.9% (25 re-ruptures) for those with an acute presentation and 2.7% (two re-ruptures) for those with delayed presentation. . This study of non-operative functional management of rupture of the tendo Achillis is the largest of its kind in the literature. Our rates of re-rupture are similar to, or better than, those published for operative treatment. We recommend our regime for patients of all ages and sporting demands, but it is essential that they adhere to the protocol

A prospective series of 32 cases with tuberculosis of the hand and wrist is presented. The mean age of the patients was 23.9 years (3 to 65), 12 had bony disease and 20 primarily soft-tissue involvement. The metacarpal of the little finger was the most commonly involved bone. Pain and swelling were the usual presenting features and discharging sinuses were seen in three cases. All patients were given anti-tubercular chemotherapy with four drugs. Operative treatment in the form of open or arthroscopic debridement, or incision and drainage of abscesses, was performed in those cases where no response was seen after eight weeks of ATT. Hand function was evaluated by the modified score of Green and O’Brien. The mean was 58.3 (25 to 80) before treatment and 90.5 (80 to 95) at the end. The mean follow-up was for 22.4 months (6 to 43). Conservative treatment was successful in 24 patients (75%). Eight who did not respond to chemotherapy within eight weeks required surgery. Although tuberculosis of hand has a varied presentation, the majority of lesions respond to conservative treatment

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The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of ‘off-ended’ fractures in children with at least two years of potential growth remaining.

A review of the pathology, mechanism, and operative treatment of recurrent dislocation of the shoulder, based on an analysis of 180 cases, with 159 operations, is presented. From this analysis the following conclusions have been made and appear to be substantiated:. 1. The pathology comprises two important elements: (a) anterior detachment of the glenoid labrum from the bone margin of the glenoid, associated with some degree of stripping of the anterior part of the capsule from the front of the neck of the scapula, found in 87 per cent. of cases examined adequately at operation; (b) defect or flattening of the posterolateral aspect of the articular surface of the head of the humerus which engages with the glenoid cavity when the arm is in external rotation and abduction; this defect is demonstrated most readily in antero-posterior radiographs taken with the humerus in 60 to 70 degrees of internal rotation and was shown to be present in 82 per cent. of cases which had been subjected to adequate radiographic examination. 2. The frequency of the humeral head defect has been under-estimated in the past, because of the difficulty of demonstrating it, particularly when the defect is small. 3. Either type of lesion alone may predispose to recurrence of the dislocation. 4. Both types of lesion are often present in the same shoulder. When this is the case the tendency to redislocation is great. 5. The initial dislocation, which results in the development of one or both these persistent structural abnormalities, may be due to very different types of injury, the commonest of which is a fall on the outstretched hand. The factor common to all these injuries is a resultant force acting on the humeral head in the direction of the anterior glenoid margin. 6. In the treatment of recurrent dislocation of the shoulder joint the Nicola operation is unreliable, and it may be associated with a recurrence rate as high as 36 per cent. It is believed that continued instability after this operation is usually due to the presence of a defect of the humeral head. 7. Operative treatment should aim at repairing, or nullifying, the effects of both types of lesion. For anterior detachment of the labrum this involves either suturing the labrum back to the glenoid margin, or constructing some form of anterior buttress, fibrous or bony: for humeral head defects it necessitates some procedure designed to limit external rotation, thus preventing the defect from coming into engagement with the glenoid cavity. Such limitation of external rotation does not constitute a significant disability

The operative treatment of displaced fractures of the tibial plateau is challenging. Recent developments in the techniques of internal fixation, including the development of locked plating and minimal invasive techniques have changed the treatment of these fractures. We review current surgical approaches and techniques, improved devices for internal fixation and the clinical outcome after utilisation of new methods for locked plating

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The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols.

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The morphology of medial malleolar fracture is highly variable and difficult to characterize without 3D reconstruction. There is also no universally accepeted classification system. Thus, we aimed to characterize fracture patterns of the medial malleolus and propose a classification scheme based on 3D CT reconstruction.