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Evidence at a glance and key questions

We have picked three recent NIHR studies, all large clinical trials, which test alternatives to open surgery for different musculoskeletal conditions. This Highlight considers some of the key points arising from the studies, but it is not a complete review of all the evidence in this area.

Key findings

For shoulder injury

  • For people aged over 50 with a long standing wear and tear injury to the shoulder, open and keyhole repair surgery gave similar outcomes and were as cost effective as each other at two years after surgery.
  • Current guidance published in 2014 offers both options, although did not recommend one treatment over the other. These findings give patients and surgeons a choice based on preference and expertise, rather than cost.

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For upper arm fractures

  • Treating a displaced fracture, near the top of the upper arm bone, with a sling worked as well as surgery to fix the broken bone and was cheaper at two years after the break. Both groups of patients (aged over 16) had physiotherapy.
  • Using a sling involved fewer complications than having surgery. For frail and older people, a sling could be a much safer treatment than surgery.
  • NICE guidance from 2016 (since this trial was published) now recommends non-surgical treatment provided the injury is not complicated, for example by the broken bone projecting through the skin.
  • Together with the new guidance, the findings could help reverse a recent trend towards doing more operations for this injury.

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For ankle fractures 

  • For people aged over 60, with an unstable fracture to the ankle, treatment with a close contact cast may be a suitable alternative to surgery to replace the ankle joint
  • NICE guidance from 2016recommends non-surgical treatment for some types of ankle fracture where there is a single break, but also mentions surgery as an option for ankle fractures in general. Close contact casting is a new type of conservative treatment for older people with unstable ankle fractures, and is not yet widely used outside of the trial for this purpose.

The findings do not mean that everyone with a shoulder injury, broken upper arm or unstable ankle fracture should have one treatment in favour of another - people will still need to discuss with their clinician which is the best for them.

Questions for patients

  • What information can you give me about my treatment options?
  • How can I get access to sufficient good quality rehabilitation to get the best out of whichever treatment I have?
  • What will my recovery be like in the short term? (days and weeks)
  • What will my recovery be like in the long term? (years)

Questions for healthcare professionals, such as surgeons and physiotherapists

  • Can you provide information about what living with the injury is like, and how to adapt everyday tasks to make them manageable?
  • Do you have information to give to patients about the treatment options and rehabilitation, that is suitable for different patients, and in different formats?
  • What are the long term outcomes of different surgical treatments?
  • What is the long term cost-effectiveness of rotator cuff injury treatments?

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