Brachial plexus tumours (BPT) and peripheral nerve sheath tumours (PNST) are largely benign in nature, with malignant tumours being rare and presenting significant surgical challenges. Excision of benign tumours may relieve pain and other symptomology. This retrospective study analysed data from 138 PNST and 92 BPT patients managed by a single consultant orthopaedic or plastic surgeon experienced in nerve tumour surgery between January 1999 to December 2019. The most common benign tumours were schwannomas and neurofibromas, with sarcomas being the most common malignant tumour. In the PNST group 30 patients were managed by observation only. Twenty patients underwent trucut biopsy, 21 patients underwent biopsy and surgical excision and 56 patients underwent surgical excision only. There were nine complications, with two significant neurological deficits requiring further surgical intervention. No recurrence of tumours occurred in this group. In the BPT group 16 patients were managed by observation only. Seven patients underwent trucut biopsy, 16 patients biopsy and surgical excision and 44 BPT patients underwent surgical excision only. Sixteen patients had complications with two significant complications requiring urgent further surgical intervention. Seven patients had recurrence of tumours which presented as metastases, with three patients requiring further surgery to remove recurrence of tumours. BPT patients are more complex and present with both benign and malignant lesions and are therefore more prone to complications due to the complex nature of the surgery and higher recurrence rate of tumours than PNST. Benign tumours in both groups can be safely managed conservatively if patients’ symptomology is acceptable

Introduction. An aneurysmatic bone cyst (ABC) is a benign cystic lesion of bone composed of blood-filled spaces separated by connective septa. The most common treatment is curettage with or without bone grafting. Curettage with bone grafting and Ethibloc injection therapy have a comparable recurrence rate. Ethibloc is a radiopaque alcohol solution of corn protein which is percutaneously injected in the ABC. Objective. To compare percutaneous Ethibloc injection (ETHI) with curettage with bone grafting (CUBG) in the treatment of ABC. Methods. We conducted a retrospective cohort study of 73 treatments on 56 patients with ABC, between 1985 and 2007. The number of treatments were divided in two groups, one consisting of treatments with ETHI (n=35) and the other of treatments with CUBG (n=38). Both groups are comparable for the number of primary lesions; ETHI (n=17) and CUBG (n=21) or recurrences; ETHI (n=18) and CUBG (n=17). Radiological and clinical outcomes were assessed pre- and post-operatively. We evaluated the outcome measures of ETHI and of CUBG during a mean of 24.7 (range: 2–48) months. We evaluated the recurrence rate in both groups for a maximum period of 4 years to prevent the influence of outliers. Recurrence was defined as a radiological progression/recurrence of the lesion or progression/persistence of symptoms (pain, tumor, function impairment). Statistical analysis included a Kaplan Meier survival analysis, a cox-regression analysis to account for potential confounders and a chi-square test. Results. A survival analysis showed no difference in recurrence rate between both groups. A cox regression analysis showed that type of treatment, after correcting for size of tumor, location and previous treatment, had no influence on recurrence rate. There was no significant difference in clinical outcome in both groups; complete relief of all symptoms was found after ETHI and CUBG n=30 (86%) and n=33 (87%) respectively. Radiologically, 24 (69%) of the treatments with ETHI were effective (no recurrence) in 24 months (range: 3–48) and 28 (74%) of the treatments with CUBG in 23 months (range: 2–48). There was no significant difference between the ETHI vs. CUBG in the number of effective treatments in both primarily treated ABC's (10 vs. 15, p=0.3) as in ABC's with previous treatments (14 vs. 13, p=0.6). Complications after ETHI consisted of 2 fistulas and after CUBG of an AVN and failure of reconstruction. Discussion. This study shows that the relatively simple, percutaneous Ethibloc injection is comparable to curettage with bone grafting, regarding both clinical and radiological outcome. Recurrence rate was not influenced by type of treatment, location or size of tumour. We recommend Ethibloc injection as the first-choice treatment of primary and recurrent ABC's

Aims

Fracture-related infections (FRIs) are a devastating complication of fracture management. However, the impact of FRIs on mental health remains understudied. The aim of this study was a longitudinal evaluation of patients’ psychological state, and expectations for recovery comparing patients with recurrent FRI to those with primary FRI.

Aims. The use of local antibiotic carriers in the treatment of chronic osteomyelitis is an important adjunct in dead space management. We present the outcomes of two different biodegradable antibiotic carriers used in the management of chronic osteomyelitis. Method. A single centre series between 2006–2017. The initial cohort (2006–2010) of 137 cases, Group A, had Osteoset® T (calcium sulphate carrier containing tobramycin). The second cohort (2013–1017) of 160 cases, group B, had CeramentTM G (biphasic calcium sulphate, nano-crystalline hydroxyapatite carrier containing gentamicin). Only Cierny-Mader Grade III and IV cases were included with a minimum six-month radiographic follow-up. Infection recurrence rate, wound leakage, subsequent fracture involving the treated segment, and radiographic void filling were assessed at a minimum of 6 months following surgery. Results. Mean follow-up in Group A was 2.5 yrs (0.5–10.5) and in Group B it was 1.4 yrs (0.6–4.7). Group A had a significantly higher rate of infection recurrence (16/137 (11.7%) Vs. 7/160 (4.4%) p=0.0278), wound leakage (26/137 (19.0%) Vs. 16/160 (10.0%) p=0.0304) and subsequent fracture rate (11/137 (8.0%) Vs. 3/160 (1.9%) p=0.0143) compared to Group B. Average time to recurrence was 1.07 years (0.1–2.6) in Group A and 1.02 (0.2–2.1) in Group B. The mean bone void healing in Group B was significantly better than Group A (73.2% Vs. 40.0%, p <0.00001). Conclusions. Cerament™ G has significantly better bone healing compared to a calcium sulphate carrier and was associated with a lower rate of recurrent infection, wound leakage and subsequent fracture risk

Background. Giant cell tumours of bone (GCT) are benign bone tumours with a locally aggressive character. Local recurrence is considered the main complication of surgical treatment and is described in up to 50% of patients. Intralesional curettage with the use of adjuvants like phenol or polymethylmetacrylate (PMMA) is recommended as initial treatment, significantly decreasing the risk of recurrence. However, risk factors for local recurrence in skeletal GCT have not yet been firmly established and a golden standard for local therapy remains controversial. Objective. The identification of risk factors predisposing for an increased risk of local recurrence. In addition, different surgical techniques are compared to identify the optimal surgical approach for the identified risk factors. Methods. In a retrospective study all 215 patients with bone GCT treated between 1964 and 2009 in one centre were included, of which 193 were suitable for analysis. All patients had minimal follow-up of 12 months (mean 115; range 12–445). Using a Kaplan Meier survival analysis recurrence free survival rates were calculated. Cox-regression was used to determine the influence of different types of therapy, the use of adjuvants, and various patient and tumour characteristics. Results. The mean local recurrence rate for all patients was 35.2% (n=68, 95%CI: 28.3–42.1). Recurrence rate after wide resection was 0.17 (n=6, 95%CI: 0.04–0.29), after curettage with adjuvants 0.32 (n=42, 95%CI 0.24–0.41) and after curettage alone 0.74 (n=20, 95%CI: 0.57–0.91, p < 0.001). Soft tissue extension (Hazard Ratio: 3.8, p < 0.001), localisation in radius and ulna (HR: 2.6, p=0.013), and surgical experience (HR: 2.2, p=0.022) were identified as significant general risk factors for local recurrence. For intralesional resection, Campanacci grade III (HR: 3.9, p=0.019) and location in axial skeleton (HR: 3.3, p=0.016) additionally significantly increased this risk. Comparing treatments our data showed that curettage followed by adjuvants was superior to curettage alone (p < 0.004), and the application of both phenol and PMMA did not present a significantly better outcome than curettage and PMMA alone (HR: 1.07, p=0.881). Conclusion. Of all possible risk factors only soft tissue extension, localisation in radius and ulna and non-radical resections significantly influenced the risk of local recurrence for all treatments. In addition, we found that high-grade tumours and localisation in the axial skeleton were additional risk factors for local recurrence after intralesional surgery. Although wide resection increases patient morbidity, it can be the therapy of choice in high risk patients. Intralesional therapy can be advised for low recurrence risk patients using curettage and PMMA only, whereas our study could not confirm the predicted effect of phenol as an additional adjuvant

Digital Mucous Cysts (DMCs) arise from the distal inter-phalangeal joints of the digits. They often rupture spontaneously and nail deformities are common. Although surgical excision is recognised as the most successful treatment, there is no clear consensus as to the most appropriate operative technique. We performed a retrospective review identifying all patients who underwent excision of a DMC using a local rotation skin flap by the senior author over a ten-year period. Patients were all seen pre-operatively and at a minimum of six months post-operatively. Sixty-nine patients were included in the study and were reviewed at an average of 37.7 months post-operatively. No patients were lost to follow-up. There was only one cyst recurrence (1.4%). Sixty-seven (97.1%) patients were happy with the scar and sixty-three patients (91.3%) said they would have the procedure performed again. Sixty-six patients (95.7%) were content with their post-operative range of movement, which was on average 8.1° less than pre-operative values. Thirty-six patients had a nail deformity pre-operatively and twenty-one reported that the deformity grew out following the procedure. Only one patient (3.0%) developed a new deformity post-operatively. Five patients reported infection post-operatively with four prescribed oral antibiotics, but all resolved following one week of treatment. This study, which is one of the largest analyses of an operative treatment for DMCs, demonstrates that cyst excision with a local rotation skin flap is a safe and effective technique with a low recurrence rate and a high patient satisfaction

Aim. To analyse our results after en-block resection of aggressive GCT during 20 years period. Methods. We review 86 patients with skeletal GCT during the last 20 years, from 1990 until 2009, retrospectively. In the cases of latent and active type, extended curettage and bone graft or cement were our treatment of choice, while in aggressive ones we performed en block resection and reconstruction by fibular autograft (e.g. in distal part of radius) or fusion/hinge joint prosthesis (e.g. in GCT around the knee joint). We describe the recurrences, metastases and complications according to treatment. Results. There was no recurrence in 18 cases of en block resection and segmental bone defects were reconstructed with fibular autograft (5), joint fusion (4) and hinge joint arthroplasty (9). We had 2 cases of pulmonary metastasis that underwent resection of the metastasis. In one case, internal fixation failed and the graft broke; thus revision was performed. The rest 68 cases underwent extended curettage and bone graft (51) or cement (17). We had 7 cases of recurrence, 6 treated with repeated curettage and bone cement and one with en lock resection. No death or major complication was reported. Conclusions. In comparison of en block resection with extended curretage, the recurrence rate is greater with the latter; however it results in good control of the disease with less morbidity. In recent years, the invention of hinge knee prosthesis has increased the quality of patients' life in whom we could not preserve the involved joint

BACKGROUND CONTEXT. Osteoporosis causes decreased bone mineral density, which predisposes to fragility fractures. Low-energy vertebral compression fractures are the most common type of osteoporotic fragility fracture. Prior studies have shown that only one-quarter of patients diagnosed with an osteoporotic fracture are referred or treated for osteoporosis. PURPOSE. To identify the rate of recurrent fractures after vertebroplasty and after the conservative treatment for patients aged 50 years and older who sustained low impact vertebral compressions fractures over a 6-month period. STUDY DESIGNED/SETTING. Prospective study. PATIENT SAMPLE. The sample included patients 50 years or older who had a low-energy vertebral compression fracture. The patients were divided into two groups: first group (n=24) - patients teated by vertebroplasty and the second group (n=34) - patients treated conservatory. There was no significant difference among the groups in terms of the vertebral levels or BMD. METHODS. Patients records were reviewed for fracture recurrence and in the same time we examined medical records for osteoporotic medication prescriptions, refferals to endocrinology and to dual-energy X-ray absorptiometry (DEXA) scans. RESULTS. Confounding factors of age at the procedure, sex and chronic steroids use were considered and found to have no statistically significant difference between the two groups and between those with fracture recurrence and those without fracture recurrence. Four vertebroplasty procedure resulted in a recurrent fracture within the first 6 months. In the patient group treated conservatory 8 patients sustained recurrent fractures. Patients with recurrent vertebral fracture didn't receive active osteoporosis treatment. Within 6 months after the fracture only 21% of patients were receiving active osteoporosis treatment. CONCLUSIONS. The incidence of recurrent fracture after vertebroplasty or after conservative treatment is substantial but have no statistically significant difference between the two groups. We consider that the recurrence rate is not related with the surgical intervention but is the result of natural history of the patient's osteoporosis because the patients do not understand the importance of initiating active therapeutic intervention for osteoporosis recommended by physicians

Introduction. Dupuytren's disease (DD) is a fibro-proliferative disorder of the palmar fascia whereby a collagen cord contracts affected joints, resulting in flexion deformity that can impair hand function. Currently, surgery is the only effective treatment option in Europe. This 2-part study, consisting of a surgeon survey and chart audit, was designed to assess current surgical practice patterns by DD severity. We report results from the surgeon survey. Methods. A total of 687 participants, including 579 orthopedic surgeons (of which 383 were hand specialists) and 108 plastic surgeons, who had been practicing for >3 and <30 years and operated on 5 DD patients between September and December 2008 were surveyed in 12 countries (UK, Germany, France, Italy, Spain, Hungary, Czech Republic, Poland, Netherlands, Sweden, Denmark, Finland). The survey included queries about procedures performed, factors involved in the decision to use a procedure, satisfaction with the procedure, use of physiotherapy, and recurrence. Results. Regardless of specialty, about 95% of surgeons performed fasciectomy in the previous 12 months. Rates for needle aponeurotomy (NA; 36%) and fasciotomy (70%) were comparable across specialties; a larger proportion of plastic surgeons (65%) used dermofasciectomy (DF) than did orthopaedic (39%) and hand surgeons (44%). Decisions to use NA/fasciotomy were driven mainly by patient comfort and quality-of-life issues (eg, aged >70 y, aesthetics, activity impairment); surgeon satisfaction was linked to shorter recovery times, reduced patient burden, few complications, and restored finger function. Decisions to use open surgeries were based mostly on DD characteristics (eg, contracture severity, speed of progression, recurrence), and surgeon satisfaction was linked to intervention efficacy and durability of the outcome. The percentage of surgeons prescribing physiotherapy and the duration of therapy increased with complexity of the first procedure: NA=86%, 5.3 weeks; fasciotomy=94%, 5.4; fasciectomy=97%, 6.7; and DF=99%, 8.7. On average, 90% of patients were enrolled in a physiotherapy program after undergoing a procedure for DD. Using survey responses, recurrence rates appeared to decrease and time to recurrence increased with procedure complexity: NA=44%, 17 months; fasciotomy=32%, 21; fasciectomy=20%, 29; and DF=20%, 34. Conclusions. To our knowledge, based on the number of participants and countries, this is the largest survey to date to collect, quantify, and describe information about the surgical management of DD in Europe. Although data from all countries were combined and results from the specialties were collapsed, it is a critical first step toward understanding DD treatment patterns. Opportunities to learn more about country- and specialty-specific practices will be presented elsewhere. This study was funded by Pfizer Inc

Introduction. It has been postulated that a mild clubfoot does better than a severe clubfoot no matter what treatment course is taken. There have been previous efforts to classify clubfoot. For units worldwide that use the Ponseti Method of clubfoot management, the Pirani scoring system is widely used. This scoring system has previously been shown to predict the number of plasters required to gain correction. Our study aimed to investigate whether the Pirani score gave an indication of longer-term outcome using tibialis anterior tendon transfer as an endpoint. Methods. A prospectively collated database was used to identify all patients treated in the Ponseti clinic at the Royal Manchester Children's Hospital between 2002 and 2005 with idiopathic clubfoot who had not received any treatment prior to their referral. Rate of tibialis tendon transfer as well as the patient's presenting Pirani score were noted. Feet were grouped for analytical purposes into a mild clubfoot (Pirani score <4) and a severe clubfoot (Pirani score 4) category depending on initial examination. Clinic records were reviewed retrospectively to identify patients who were poorly compliant at wearing boots and bars and were categorised into having “good” or “bad” compliance with orthosis use. Results. 132 feet in 94 children were included in the study. 30 (23%) tibialis tendon transfers were performed at a mean of 4.2 years (range 2.3–5.5 years). Children with severe clubfoot had a significantly higher rate of tendon transfer compared with those with mild clubfoot (28% vs. 6%; p=0.0001). 81% of patients were classified as being “good” boot wearers. Tibialis tendon transfer rates in those who were poorly compliant with boot usage were significantly higher compared with those with good compliance (52% vs. 16%; p=0.0003). There was a significantly higher tendon transfer rate in those with severe disease and poor compliance compared with good compliance (69% vs. 20%; p=0.0002). There was no association between boot compliance and tendon transfer rates in those with mild disease. Conclusion. This study shows that late recurrences, requiring tibialis anterior tendon transfer, are associated with severity of disease at presentation and compliance with use of orthoses. Tendon transfer rates are higher for those with severe disease. We have confirmed previous reports that compliance with orthotic use is associated with recurrence. However, the novel findings regarding recurrence rates in mild clubfeet may have implications regarding usage of orthoses in the management of mild idiopathic clubfeet after initial manipulation using the Ponseti method

The generally-accepted treatment for large, displaced fractures of the glenoid associated with traumatic anterior dislocation of the shoulder is operative repair. In this study, 14 consecutive patients with large (> 5 mm), displaced (> 2 mm) anteroinferior glenoid rim fractures were treated non-operatively if post-reduction radiographs showed a centred glenohumeral joint.

After a mean follow-up of 5.6 years (2.8 to 8.4), the mean Constant score and subjective shoulder value were 98% (90% to 100%) and 97% (90% to 100%), respectively. There were no redislocations or subluxations, and the apprehension test was negative. All fragments healed with an average intra-articular step of 3.0 mm (0.5 to 11). No patient had symptoms of osteoarthritis, which was mild in two shoulders and moderate in one.

Traumatic anterior dislocation of the shoulder, associated with a large displaced glenoid rim fracture can be successfully treated non-operatively, providing the glenohumeral joint is concentrically reduced on the anteroposterior radiograph.