Open reduction and internal fixation for unstable fractures of the lateral end of the clavicle (Neer type II) is not complication-free. Most clavicle fractures can be successfully treated by conservative methods. Neer type II fractures have a reportedly high rate of nonunion, therefore internal fixation is recommended. However, the need for surgical treatment remains controversial as nonunion seldom produces a poor functional outcome. We report 3 cases of fixation failure following treatment with a clavicular hook plate. None of the patients required re-fixation surgery and all achieved bony union with a good functional result.

Eighteen patients attending an orthopaedic outpatient clinic with a year or more's history of heel pain due to plantar fasciitis were studied. All had had conservative treatment of physiotherapy and shoe-support without significant pain relief before acupuncture was offered, and thus acted as their own controls for the purposes of the study. The following traditional points were needled: Taixi (KI.3), Kunlun (BL.60) and Sanyinjiao (SP.6). Pain was assessed by a 100mm visual analogue scale (VAS) before treatment was started and after four, weekly sessions of acupuncture treatment. If complete pain relief was not obtained by the initial four-week treatment, a further two, weekly sessions of the above mentioned acupoints, with the addition of trigger point acupuncture in the gastro-soleus and plantar fascia, was carried out and pain assessed. Patients were also assessed with a verbal rating score to indicate the percentage improvement after acupuncture compared to before treatment. The mean duration of heel pain was 25.11 months (SD 10.68). The VAS data obtained at 4 and 6 weeks of acupuncture treatment showed a statistically highly significant improvement compared to the VAS before acupuncture (p < 0.0009 and p < 0.0001 respectively). Using the Mann-Whitney test, there was a statistically significant difference in VAS obtained at 6 weeks, after trigger point acupuncture had been added for poor responders, compared to that obtained after the first 4 weeks of acupuncture treatment (p < 0.047). Our study demonstrates that acupuncture is effective in treating patients with chronic heel pain due to plantar fasciitis and that the addition of trigger point acupuncture in poor or non-responders may be useful.

We report a prospective controlled trial, comparing acupuncture with no treatment, in patients with advanced osteoarthritis of the knee awaiting total knee replacement. Knee function was assessed at the beginning of study and at the end of two months, using four parameters: HSS score, time to walk 50 metres, time to climb 20 steps, and degree of pain. Acupuncture was given at four local points around the knee and at one distal point. The acupuncture group improved in all parameters, whereas the control group deteriorated, a finding that was highly statistically significant (p<0.0002). Further randomised-controlled trials with longer follow-up are required to confirm these findings.

SummaryThe role of acupuncture analgesia in the management of postoperative pain is yet to be clearly evaluated. We conducted a prospective, double-blind, randomised controlled study to evaluate the effect of acupuncture pretreatment on the analgesic requirement after knee arthroscopy. Forty-two patients presenting for unilateral knee arthroscopy were randomly allocated to receive a standard anaesthetic with or without acupuncture (given after the induction of anaesthesia). Visual analogue pain scores, time to first postoperative analgesia and total analgesia requirement in the first 24 h were recorded. There was no significant difference between the two groups in any of the outcome measures. We conclude that acupuncture analgesia has no additional effect when given under anaesthesia to patients undergoing knee arthroscopy. There has been much interest in acupuncture as a method of analgesia in the West over recent years [1]. Various explanations have been forthcoming regarding the mechanisms by which it may work. The activation of central inhibitory mechanisms has been emphasised [2, 3]. Brief periods of activity in nociceptive afferents from deep tissues, produced for example by surgery, induce excitability changes in central neurones [4]. In an editorial based on these and other results, Wall [5] stressed the importance of pre-and intra-operative measures in trying to reduce or inhibit the development of this hyperexcitablity (e.g. pre-emptive analgesia) which might result in reduced postoperative pain.If acupuncture acts by reducing central hyperexcitability (possibly by the central release of endorphins) then it could be an effective method of pre-emptive analgesia. This project was a prospective, double-blind, randomised controlled study to determine whether acupuncture given after induction of anaesthesia, but before surgical stimulus, has any additional effect over standard analgesia. Methods

We report a prospective randomised trial of acupuncture given to 44 patients with advanced osteoarthritis (OA) of the knee awaiting total knee joint replacement. Patients were randomly allocated into two groups, group A receiving acupuncture to the most affected knee only and group B receiving acupuncture to both knees. Acupuncture was given to four local points around the knee and one distal point. The local points were Spleen 9 (Yinlinquan, SP9), Spleen 10 (Xuehai, SP10), Stomach 34 (Liangqui, ST34), and Stomach 36 (Zusanli, ST36). The distal point was Large Intestine 4 (Hegu, LI4) on the first web space of the ipsilateral hand. A blinded observer assessed knee function before starting treatment, and at the end of two and six months. Analysis of the results showed a significant reduction in symptoms in both groups, and this improvement was sustained for six months. There was no statistically significant difference between the groups. In conclusion, unilateral acupuncture is as effective as bilateral acupuncture in increasing function and reducing the pain associated with OA of the knee. This trial is not able to distinguish the specific from the non-specific effects of the treatment.