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

OBJECTIVES. In elderly patients the temporary loss of function of the upper extremity due to immobilization for treatment of unstable proximal humeral fractures is a very disabling condition. Stable fixation of such fractures allowing immediate functional aftercare may contribute to early social reintegration in this group of patients. Aim of this study is to present the surgical technique of humeral blade plate fixation and the clinical and radiographic results after fixation of unstable surgical neck fractures with this implant followed by immediate functional treatment in patients older than 60 years. PATIENTS. 20 patients (4 male, 16 female) with a mean age of 74 years (59y–93y) were included in this study and treated consecutively for an unstable/displaced surgical neck fracture with a humeral blade plate. Postoperatively functional treatment was allowed. All but one patient had a clinical and radiographic follow-up 6 weeks po. At an average final follow-up of 18,8 months (12–24 months) 4 patients had died from causes unrelated to surgery. RESULTS. Surgery was performed in all patients without local or general complications despite comorbidities. In all patients anatomic reduction and stable fixation could be achieved. 6 weeks po all patients (N=20) were free of pain at rest, 7 patients had low pain (VAS < 4) when actively moving the arm. All patients used their operated arm for ADL and were back home or in the institution they came from at the time of trauma. All fractures were deamed to be healed without implant failure. In two cases a clinically asymptomatic 1–2mm protrusion of the blade through the subchondral bone was observed, but did not required further surgery. At final follow-up (N=8) the average absolute Constant/Murley Score was 68,6 points (contralateral 71,4). Radiographically all fractures had healed without complications. Implant removal was not required. CONCLUSION. Humeral blade plate fixation combined with suture tension-banding of the rotator cuff allows indirect reduction, dynamic and stable osteosynthesis of unstable surgical neck fractures even in osteoporotic bone. In our small series, this technique has shown to be a safe and reliable therapeutic option allowing immediate functional treatment and thus early social reintegration in elderly patients

Isolated Weber B fractures usually heal uneventfully but traditionally require regular review due to the possibility of medial ligament injury allowing displacement. Following recent studies suggesting that delayed talar shift is uncommon we introduced a functional treatment protocol and present the early results. 86 patients presenting acutely with Weber B fractures without talar shift between January and July 2015 were included. Patients were splinted in a removable boot and allowed to weight bear. ED notes and radiographs were reviewed by an Orthopaedic consultant. Patients without signs of medial injury were discharged with an information leaflet and advice. If signs of medial ligament injury were noted or the medial findings were not documented the patient was reviewed in fracture clinic at 4 weeks post-injury. If talar shift developed the patient was to be converted to operative treatment. MOXFQ and EDQ5 scores were collected. 50 patients had signs of medial ligament injury or no documented medial findings and of these 43 attended fracture clinic. Of 36 patients without signs of medial ligament injury 28 were discharged according to protocol and 8 patients attended fracture clinic. One discharged patient re-accessed care. Of 52 patients reviewed in the fracture clinic none developed delayed talar shift and all continued with non-operative treatment. The outcome scores were comparable to those in the published literature. We conclude the risk of delayed talar shift is low and satisfactory outcomes can be safely achieved with our functional protocol. Additional tests/imaging to establish the integrity of the medial ligament may be unnecessary

In 42 elderly patients, 33 women and nine men with a mean age of 72 years, we treated displaced fractures of the proximal humerus (34 three-part, 8 four-part) using a blade plate and a standard deltopectoral approach. Functional treatment was started immediately after surgery. We reviewed 41 patients at one year and 38 at final follow-up at 3.4 years (2.4 to 4.5). At the final review, all the fractures had healed. The clinical results were graded as excellent in 13 patients, good in 17, fair in seven, and poor in one. The median Constant score was 73 ± 18. Avascular necrosis of the humeral head occurred in two patients (5%). We conclude that rigid fixation of displaced fractures of the proximal humerus with a blade plate in the elderly patient provides sufficient primary stability to allow early functional treatment. The incidence of avascular necrosis and nonunion was low. Restoration of the anatomy and biomechanics may contribute to a good functional outcome when compared with alternative methods of fixation or conservative treatment. Regardless of the age of the patients, we advocate primary open reduction and rigid internal fixation of three- and four-part fractures of the proximal humerus

Introduction. Conservative treatment of Achilles tendon ruptures may lead to re-rupture. Open surgical repair entails a risk of skin necrosis or infection. Several percutaneous techniques have been used, like Tenolig® or Achillon®, but these techniques are costly and may be marred by wound healing problems. Ma and Griffith described a technique for percutaneous repair witch left the suture and the knot under the skin, thus reducing the risk for infection. Material and Methods. From January 2001 to September 2006, we used this percutaneous treatment for 60 acute ruptures of Achille tendon. The repair was made under local anaesthesia, using a single or double absorbable suture. Postoperative care was 3 weeks immobilisation in a cast in equinus position with no weight bearing, followed by another 3 weeks in a cast with the ankle at 90° with progressive weight bearing. Results. Mean follow-up was 19 months. Complications were 2 re-ruptures at 2 and 5 months respectively, 1 infection in a patient who presented with re-rupture after a previous surgical treatment, and 1 Achilles tendonitis. There was no sural nerve lesion. Mean time to return to working activities was 85 days and mean time to return to sports activities was 5 months. The three competitive sportsmen returned to sports at six months, at the same level. Monopodal weight-bearing was possible for all the patients except one. Hopping was not possible in eight cases. Walking on tiptoe was not possible in four cases. A 5° limitation of dorsiflexion of the ankle was observed in four patients. Clinical results were good with no loss in range of motion. The patients’ subjective evaluation was as follows: 18 judged the outcome as very satisfactory, 40 as satisfactory and two as poor. Discussion. The percutaneous suture technique used in this series differs from other methods of surgical repair in being inexpensive. The only specific equipment required is a long needle with an eyelet, sufficiently rigid to transfix the tendon. In this study we had used a custom needle as the prototype of the “Suturach®” (FH Orthopedics, Heimsbrunn, France) needle which we now use. The technique does not require expensive surgical material and above all, does not leave any foreign body externally in contact with the skin (5) which could be a source of local inflammation, or even of cutaneous necrosis (12). This is particularly important for countries with a hot climate where it is not customary to wear closely fitting shoes. The technique used is reliable, reproducible and easily taught. In this series, it was performed by a number of operators with various levels of training. Conclusion. Percutaneous suture of the Achilles tendon appears as a simple, rapid, effective, reproducible and inexpensive technique. It combines the advantages of open surgery with a low risk of re-rupture and those of functional treatment with a low risk of infection

The current standard for treatment of humeral shaft fractures is in a functional humeral brace. Aims: To further assess the union rate for this mode of treatment and to delineate and any fracture type less likely to go on to union. Retrospective radiographic and clinical review of 199 consecutive acute adult humeral shaft fractures. 43 operated on acutely (including all open fractures). Remaining 156 fractures treated in a humeral brace. Non union was determined as delayed fracture fixation or no evidence of union at 1 year. Union rate 82.9% with 88.5% follow-up. 16 of the 24 non unions were proximal third (all but one spiral/oblique): 71.4% union rate. Middle third fractures 87.3% and distal third shaft fractures 88.9 % union rate. Union rate of fractures with 3+ parts inclusive of all regions of the shaft was 95.6%. The union rate in this study is not as high as has previously been reported for functional brace treatment. A lower threshold for intervention in proximal third spiral/oblique humeral shaft fractures may be indicated. Fracture site comminution is a very good prognostic indicator

A total of 20 patients with a depressed fracture of the lateral tibial plateau (Schatzker II or III) who would undergo open reduction and internal fixation were randomised to have the metaphyseal void in the bone filled with either porous titanium granules or autograft bone. Radiographs were undertaken within one week, after six weeks, three months, six months, and after 12 months.

The primary outcome measure was recurrent depression of the joint surface: a secondary outcome was the duration of surgery.

The risk of recurrent depression of the joint surface was lower (p < 0.001) and the operating time less (p < 0.002) when titanium granules were used.

The indication is that it is therefore beneficial to use porous titanium granules than autograft bone to fill the void created by reducing a depressed fracture of the lateral tibial plateau. There is no donor site morbidity, the operating time is shorter and the risk of recurrent depression of the articular surface is less.

Cite this article: Bone Joint J 2015; 97-B:836–41

We performed a systematic review of the literature to evaluate the use and interpretation of generic and disease-specific functional outcome instruments in the reporting of outcome after the surgical treatment of disruptions of the pelvic ring. A total of 28 papers met our inclusion criteria, with eight reporting only generic outcome instruments, 13 reporting only pelvis-specific outcome instruments, and six reporting both. The Short-Form 36 (SF-36) was by far the most commonly used generic outcome instrument, used in 12 papers, with widely variable reporting of scores. The pelvis-specific outcome instruments were used in 19 studies; the Majeed score in ten, Iowa pelvic score in six, Hannover pelvic score in two and the Orlando pelvic score in one. Four sets of authors, all testing construct validity based on correlation with the SF-36, performed psychometric testing of three pelvis-specific instruments (Majeed, IPS and Orlando scores). No testing of responsiveness, content validity, criterion validity, internal consistency or reproducibility was performed.

The existing literature in this area is inadequate to inform surgeons or patients in a meaningful way about the functional outcomes of these fractures after fixation.

We retrospectively analysed the clinical results of 30 patients with injuries of the sternoclavicular joint at a minimum of 12 months’ follow-up. A closed reduction was attempted in 14 cases. It was successful in only five of ten dislocations, and failed in all four epiphyseal disruptions. A total of 25 patients underwent surgical reduction, in 18 cases in conjunction with a stabilisation procedure.

At a mean follow-up of 60 months, four patients were lost to follow-up. The functional results in the remainder were satisfactory, and 18 patients were able to resume their usual sports activity at the same level. There was no statistically significant difference between epiphyseal disruption and sternoclavicular dislocation (p > 0.05), but the functional scores (Simple Shoulder Test, Disability of Arm, Shoulder, Hand, and Constant scores) were better when an associated stabilisation procedure had been performed rather than reduction alone (p = 0.05, p = 0.04 and p = 0.07, respectively).

We recommend meticulous pre-operative clinical assessment with CT scans. In sternoclavicular dislocation managed within the first 48 hours and with no sign of mediastinal complication, a closed reduction can be attempted, although this was unsuccessful in half of our cases. A control CT scan is mandatory. In all other cases, and particularly if epiphyseal disruption is suspected, we recommend open reduction with a stabilisation procedure by costaclavicular cerclage or tenodesis. The use of a Kirschner wire should be avoided.