Aims. Ankle fractures are common, mainly affecting adults aged 50 years and over. To aid recovery, some patients are referred to physiotherapy, but referral patterns vary, likely due to uncertainty about the effectiveness of this supervised rehabilitation approach. To inform clinical practice, this study will evaluate the effectiveness of supervised versus self-directed rehabilitation in improving ankle function for older adults with ankle fractures. Methods. This will be a multicentre, parallel-group, individually randomized controlled superiority trial. We aim to recruit 344 participants aged 50 years and older with an ankle fracture treated surgically or non-surgically from at least 20 NHS hospitals. Participants will be randomized 1:1 using a web-based service to supervised rehabilitation (four to six one-to-one physiotherapy sessions of tailored advice and prescribed home exercise over three months), or self-directed rehabilitation (provision of advice and exercise materials that participants will use to manage their recovery independently). The primary outcome is participant-reported ankle-related symptoms and function six months after randomization, measured by the Olerud and Molander Ankle Score. Secondary outcomes at two, four, and six months measure health-related quality of life, pain, physical function, self-efficacy, exercise adherence, complications, and resource use. Due to the nature of the interventions, participants and intervention providers will be unblinded to treatment allocation. Conclusion. This study will assess whether supervised rehabilitation is more effective than self-directed rehabilitation for adults aged 50 years and older after ankle fracture. The results will provide evidence to guide clinical practice. At the time of submission, the trial is currently completing recruitment, and follow-up will be completed in 2024. Cite this article: Bone Jt Open 2024;5(6):499–513

Challenging shoulder cases will be presented and discussed by a panel of experts in the field. Emphasis will be on restoring glenohumeral anatomy, repairing or reconstructing the rotator cuff, and supervising rehabilitation. Different surgical options and new emerging technologies will be reviewed while highlighting the pros and cons of each

Stress fractures of the pars interarticularis of the lumbar spine in professional fast bowlers have become commonplace in modern times with a recently reported prevalence of 16.1%. We report 25 years of experience in the management of this patient group. Between 1982 and 2007, we diagnosed pars defects in 21 professional cricketers. 8 were managed conservatively by a combination of rest, supervised rehabilitation, bowling action analysis and re-training to a ‘safe’ action. Surgery was considered in those players who did not respond to these conservative measures and this group essentially compromised of the fast bowlers. Surgery was by Buck’s direct repair of the pars lesion. This treatment regime has given very good results enabling all of these players to return to professional sport with an average follow-up of over 5 years. Two of the surgical group have over 10 years follow-up and 4 have played to international level subsequent to their surgery. We recommend treatment of this group of sportsmen in a unit consisting of a specialist physiotherapist, a bowling coach and a spinal surgeon. Should conservative measures fail, we recommend Buck’s repair as the operation of choice

Hamstring muscle strain is a common sports related injury. It has been reported in a variety of sports, following acceleration or deceleration while running or jumping. Injury may vary from simple muscle strains to partial or complete rupture of the hamstring origin. Avulsion fracture of the ischial tuberosity has also been described. Simple hamstring muscle strains are treated conservatively. Surgical exploration and repair is currently advocated for partial or complete rupture of the hamstring origin. A few case series exists in literature suggesting the benefits of early intervention. We report a series of 8 athletes who presented between 2002 and 2006 with complete tear of their hamstring origin. Avulsion of the ischial tuberosity was excluded in these cases. After confirming the diagnosis, early surgical exploration and repair or reattachment was performed. The patients were braced for 8 weeks. This was followed by specialist physiotherapy and a supervised rehabilitation programme over 6 months. All patients were followed up to monitor return to normal activities and sports. The sciatic nerve was scarred to the avulsed tendon in three cases. Neurolysis led to a rapid relief of symptoms. Cases where the hamstring origin had retracted more than 3 cm required a figure 7 incision. There were no major complications including nerve palsies. An excellent functional outcome was noted by 12 months in all 8 patients. 7 of them returned to their previous level within 6-9 months of injury. One person despite a very good recovery, opted out of sports. No other complications were seen as a result of the surgical procedure. In conclusion, a tear of the origin of hamstring muscles is a significant injury. Early surgical repair and physiotherapy is associated with a good outcome and enables an early return to high level sports

The physical demand of the modern game of cricket on the fast bowler is known to cause stress fractures of the lumbar spine. Between 1983 and 2001, we diagnosed pars interarticularis defects in 18 professional cricketers contracted to a single English county cricket club. Initial management was conservative based on a combination of rest, supervised rehabilitation, bowling action analysis and re-education if indicated. Re-deployment (for example an all rounder to concentrate on batting alone) was also considered. 8 of the patient group responded to these measures. The remaining 10 were treated surgically, 9 by Buck’s repair of the spondylolytic lesion. All 9 returned to professional sport with an average follow-up of 5 years 8 months and a maximum follow-up of 10 years. We recommend treatment of this group of sportsmen in a unit consisting of a specialist physiotherapist, a bowling coach and a spinal surgeon. Should conservative measures fail, we recommend Buck’s repair as the operation of choice. Whether treated conservatively or surgically, we believe the vast majority of this patient group should be able to return to full professional sport

Prosthetic replacement of the humeral head for fracture remains an operative challenge to even the most experienced orthopaedic surgeon. Although most fractures of the proximal humerus are minimally displaced and treated conservatively, more complex fractures require operative intervention. In this respect, the four-part proximal humerus fracture and fracture-dislocation have been difficult to evaluate and manage. Results from conservative treatment have been consistently unsatisfactory while results from surgery have been more variable with some series reporting satisfactory results. Treatment options for four-part fractures and fracturedislocations of the proximal humerus fractures include non-operative management, open reduction internal fixation, and humeral head replacement. Because of the poor results with non-operative, resection arthroplasty, and internal fixation, Neer in 1951 introduced prosthetic arthroplasty with tuberosity reconstruction for these complex fractures. Many reports in the literature have documented the successful results of this procedure. In our series of 65 shoulders there were 82% satisfactory results, 97% pain relief, and 85% good functional results. Therefore, prosthetic replacement of acute displaced fractures is technically demanding but offers a predictive result of a pain-free shoulder and functional motion through aggressive rehabilitation. Our goals in this video are to provide stepwise, comprehensive information on the techniques and guidelines for humeral head replacement in the treatment of complex proximal humerus fractures. Careful preoperative planning, patient evaluation, imaging, meticulous operative techniques, and a closely supervised rehabilitation program are necessary to produce a successful functional shoulder after prosthetic reconstruction

This study sought to determine the post-operative management of spinal patients in the UK, and to determine if uniformity exists between surgeons and if there is any published evidence for this practice. A reply-paid questionnaire was sent to members of the British Association of Spinal Surgeons and the Society for Back Pain Research. The questionnaire documented the surgeon’s experience, where they work, their operative population, the types of spinal surgery performed, and whether they have a routine for post-operative management or any written instructions for patients concerning post operative management. It also asked about the nature and duration of professionally supervised rehabilitation. Of the 89 questionnaires distributed, 63 (71%) were returned, of which 51 could be used in the analysis. The 12 not used were either completed incorrectly, had missing data or the surgeon had since retired. The replies demonstrated wide variation: only 35% of surgeons provide their patients with written post-operative instructions; there was limited referral to physiotherapy, with only 45% referring to a physiotherapist (for an average of 1.8 sessions); only a modest fraction of surgeons advocated the use of a post-operative corset (18%), others restricting sitting or encouraging bed rest; and a range of recommendations regarding return to work. There was also only a limited correlation between restrictions on sitting and recommendations about return to sedentary work or driving (Spearman r=0.08 and 0.36, respectively). In summary, although individual surgeons may be certain of their practice, the overall variation indicates ongoing uncertainty across the profession. This was further substantiated by our literature search, which revealed limited evidence for current practices, and a paucity of research into postoperative management

Aims

To determine whether platelet-rich plasma (PRP) injection improves outcomes two years after acute Achilles tendon rupture.