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Unlabelled: This systematic review assesses the quality and outcomes of published articles concerning bone graft surgery for scaphoid fracture non-union. Searches of the CENTRAL, MEDLINE, EMBASE, CINAHL and AMED databases captured 2710 articles. Each article was screened and 144 met our inclusion criteria. Data regarding source, study design, population, intervention, comparator and outcomes were extracted. There were 5464 scaphoid non-union outcomes within the 144 studies. Mean reported union rates for vascularized and non-vascularized bone graft were 84% and 80%, respectively. Avascular necrosis was diagnosed in several ways and, when present, the vascularized bone graft union rate was 74% compared with 62% with non-vascularized bone graft. Reported union rates vary considerably. These differences may be due to patient factors, fracture factors, treatment factors or study design failures or bias. We recommend that future researchers take into account the deficiencies of previous studies and use the suggested minimum data set in future studies., Level of Evidence: II., (© The Author(s) 2015.)

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., (©2015 The British Editorial Society of Bone & Joint Surgery.)

Background: The aim of this study was to compare the outcomes of displaced distal radial fractures treated with a volar locking plate with the results of such fractures treated with a conventional method of closed reduction and percutaneous wire fixation with supplemental bridging external fixation when required. Our aim was to ascertain whether the use of a volar locking plate improves functional outcomes., Methods: A single-center, pragmatic, randomized controlled trial was conducted in a tertiary care institution. One hundred and thirty patients (eighteen to seventy-three years of age) who had a displaced distal radial fracture were randomized to treatment with either a volar locking plate (n = 66) or a conventional percutaneous fixation method (n = 64). Outcome assessments were conducted at six weeks, twelve weeks, and one year. Outcomes were measured on the basis of scores on the Patient Evaluation Measure (PEM) and QuickDASH questionnaire (a shortened version of the Disabilities of the Arm, Shoulder and Hand, or DASH, Outcome Measure), EuroQol-5D (EQ-5D) scores, wrist range of motion, grip strength, and radiographic parameters., Results: The rate of follow-up at one year was 95%. Patients in the volar locking-plate group had significantly better PEM and QuickDASH scores and range of motion at six weeks compared with patients in the conventional-treatment group, but there were no significant differences between the two groups at twelve weeks or one year. Grip strength was better in the plate group at all time points. The volar locking plate was better at restoring palmar tilt and radial height. Significantly more patients in the plate group were driving at the end of six weeks, but this did not translate to a significant difference between groups in terms of those returning to work by that time., Conclusions: Use of a volar locking plate resulted in a faster early recovery of function compared with use of conventional methods. However, no functional advantage was demonstrated at or beyond twelve weeks. Use of the volar locking plate resulted in better anatomical reduction and grip strength, but there was no significant difference in function between the groups at twelve weeks or one year. The earlier recovery of function may be of advantage to some patients., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The outcomes of 218 little finger metacarpal shaft and neck fractures that had been treated non-operatively, with no attempt at fracture reduction, were compared with those of 44 that had been treated operatively with fracture reduction and fixation (plates or K-wires). Outcome measures included the grip strength of the little finger and the DASH score. Fracture malunion was assessed by clinical measurement of little finger ray shortening and measurement of palmar angulation on the initial radiographs. The severity of palmar angular deformity did not affect the outcome of the 105 metacarpal neck or 113 metacarpal shaft fractures that had been treated non-operatively. There were no differences between the outcomes of the 18 metacarpal neck fractures treated operatively and the 105 treated non-operatively. The DASH score (P = 0.001) and aesthetic outcome (P = 0.013) were significantly better for the 113 metacarpal shaft fractures treated non-operatively than for the 26 treated operatively.

Fractures of the distal radius occurring in young adults are treated increasingly by open surgical techniques, partly because of concern that failure to restore the alignment of the fracture accurately may cause symptomatic post-traumatic osteoarthritis in future years. We reviewed 106 adults who had sustained a fracture of the distal radius between 1960 and 1968 and who were below the age of 40 years at the time of injury. We carried out a clinical and radiological assessment at a mean follow-up of 38 years (33 to 42). No patient had required a salvage procedure. While there was radiological evidence of post-traumatic osteoarthritis after an intra-articular fracture in 68% of patients (27 of 40), the disabilities of the arm, shoulder and hand (DASH) scores were not different from population norms, and function, as assessed by the Patient Evaluation Measure, was impaired by less than 10%. Ordinal logistic regression analysis showed a significant relationship between narrowing of the joint space and extra-articular malunion (dorsal angulation and radial shortening) as well as intra-articular injury. Multivariate analysis revealed that grip strength had fallen to 89% of that of the uninjured side in the presence of dorsal malunion, but no measure of extra-articular malunion was significantly related to either the Patient Evaluation Measure or DASH scores. While anatomical reduction is the principal aim of treatment, imperfect reduction of these fractures may not result in symptomatic arthritis in the long term, and this should be considered when counselling patients on the risks and benefits of the many treatment options available.

Nineteen patients with a dorsal fracture-dislocation of the proximal interphalangeal joint of a finger were treated with either closed reduction and transarticular Kirschner wire fixation (eight cases) or open reduction and internal fixation, using either one or two lag screws (six cases) or a cerclage wire (five cases). At a mean follow-up of 7 (range 6-9) years, most patients reported satisfactory finger function, even though some of the injuries healed with proximal interphalangeal joint incongruency (seven cases) or subluxation (four cases). Those treated by open reduction complained of more "loss of feeling" in the affected finger and those specifically treated by cerclage wire fixation reported more cold intolerance and had a significantly larger fixed flexion deformity (median, 30 degrees : range 18-38 degrees ) and a smaller arc of motion (median, 48 degrees : range 45-60 degrees ) at the proximal interphalangeal joint, despite having the best radiological outcomes. Closed reduction and transarticular Kirschner wire fixation produced satisfactory results, with none of the eight patients experiencing significant persistent symptoms despite a reduced arc of proximal interphalangeal joint flexion (median=75 degrees ; range 60-108 degrees ). The results of this relatively simple treatment appear at least as satisfactory as those obtained by the two techniques of open reduction and internal fixation, both of which were technically demanding.

Background: Fractures of the shaft of the tibia often heal with some angulation. Although there is biomechanical evidence that such angulation alters load transmission through the joints of the lower limb, it is not clear whether it can eventually lead to osteoarthritis., Methods: One hundred and sixty-four individuals who had sustained a tibial shaft fracture were assessed in a research clinic thirty to forty-three years after the injury. The subjects were evaluated with regard to self-reported lower limb joint pain, stiffness, and disability (assessed with the Western Ontario and McMaster Universities [WOMAC] osteoarthritis questionnaire); clinical signs of osteoarthritis; and radiographic evidence of osteophytes and joint-space narrowing in the knees, ankles, and subtalar joints., Results: Twenty-two (15%) of the 151 subjects who reported no other knee injury reported at least moderate knee pain, and eight (6%) of the 145 subjects who reported no other ankle injury reported at least moderate ankle pain. Seventeen (13%) of the 135 subjects who reported no other knee or ankle injury reported at least moderate disability. The ipsilateral side demonstrated a higher prevalence than the contralateral side in terms of pain with passive ankle movement (nineteen versus nine subjects, p = 0.02), pain with passive subtalar movement (fifteen versus four subjects, p = 0.01), and radiographic signs of ankle joint space narrowing (twelve subjects versus one subject, p = 0.0055). Knee osteoarthritis was frequently bilateral. Forty-seven fractures (29%) healed with coronal angulation of > or = 5 degrees. Apart from an association between shortening of > or = 10 mm and self-reported knee pain (p = 0.016), there were no significant univariate associations between these malunions and the development of osteoarthritis. Seventeen (15%) of 114 eligible subjects had overall malalignment of the lower limb, defined as a hip-knee-ankle angle outside the normal range of 6.25 degrees of varus to 4.75 degrees of valgus. This malalignment was due to the fracture malunion in nine subjects and predated the fracture in eight. In limbs with varus or valgus malalignment, there was an excess of subtalar stiffness (p = 0.04) and a nonsignificant trend toward more frequent knee pain. In limbs with varus malalignment, there was a nonsignificant trend toward more frequent radiographic evidence of osteoarthritis in the medial compartment of the knee joint. Most of the subjects in whom osteoarthritis was observed had normal overall alignment of the lower limb., Conclusions: The thirty-year outcome after a tibial shaft fracture is usually good, although mild osteoarthritis is common. Fracture malunion is not the cause of the higher prevalence of symptomatic ankle and subtalar osteoarthritis on the side of the fracture. Although varus malalignment of the lower limb occurs occasionally and may cause osteoarthritis in the medial compartment of the knee, other factors are more important in causing osteoarthritis after a tibial shaft fracture.

Ten patients who had sustained 11 unstable dorsal fracture-dislocations of finger proximal interphalangeal joints were reviewed at a mean follow-up of 16 years. All had been treated acutely by closed reduction and transarticular Kirschner wire fixation of the proximal interphalangeal joint, without any attempt at reduction of the fracture of the base of the middle phalanx, which probably involved 30-60% of the articular surface. Seven of the ten patients complained of no finger pain or stiffness, and none complained of severe pain. There was a mean fixed flexion deformity of 8 degrees at the proximal interphalangeal joint, which had a mean arc of movement of 85 degrees. Although subchondral sclerosis and mild joint space narrowing were observed in some instances, there were no severe degenerative changes. These results confirm that this technique is a reliable treatment method for these injuries, and produces satisfactory long-term results., (Copyright 2001 The British Society for Surgery of the Hand.)

Twenty-two displaced metacarpal shaft fractures in 19 patients were stabilized with multiple intramedullary K-wires. These were inserted percutaneously through a small window in the base of the metacarpal and were buried in the bone. No external splintage was routinely used postoperatively and all patients were encouraged to mobilize their fingers immediately: formal physiotherapy was not usually required. All the fractures that we were able to follow-up united, but the K-wires bent at the fracture site in two instances, producing 20 degrees angular deformities. The buried K-wires had to be removed in one instance as a result of protrusion into the carpometacarpal joint.

In a prospective study we assessed the causes of mechanical failure in a series of 230 intertrochanteric femoral fractures which had been internally fixed with either a sliding hip screw or a Küntscher Y-nail. The overall rate of mechanical failure was 16.5%; cutting-out of the implant from the femoral head was the cause in three-quarters of the instances. Implants placed posteriorly in the femoral head cut out more often (27%) than those placed centrally (7%). The cut-out rate was also determined by the quality of the fracture reduction, but age, walking ability and bone density (assessed by the Singh grade and metacarpal indices) had no significant influence. We conclude that these fractures should be reduced as accurately as possible and it is imperative that the implant is placed centrally within the femoral head.