Conservative Treatment Modalities Research Articles

Evidence-based treatment of osteoporotic vertebral compression fracture

The prevalence and medical costs of osteoporotic vertebral compression fractures (OVCFs) are on the rise. However, a concrete evidence-based treatment guideline has not yet been established. Despite that numerous randomized controlled trials (RCTs) were performed, the study design and outcome measurement were heterogeneous, and the results were not unified. The purpose of this review is to compare the results of high level-evidence studies to provide a background for evidence-based OVCF treatment. Many reports showed that vertebroplasty has better clinical outcomes than non-surgical treatment for OVCF, but the results of three double-blinded RCTs with the highest level of evidence did not show a significant difference between vertebroplasty and sham procedure. Whether undergoing surgical or non-surgical treatment, OVCF patient management should be started by managing osteoporosis first. Meanwhile, in the results of RCTs related to the comparison of conservative treatment modalities, the benefit of braces and a specific analgesic prescription protocol was also unclear. The presented results of each clinical trial were generally inconsistent and may not be appropriate in all situations. Any decision by clinicians to apply this evidence must be made considering individual patients and available resources. At present, controversy remains about the best treatment modality for OVCF. Large, multicenter, placebo/sham-controlled trials are needed to address this gap and establish strong evidence-based guidelines.

Endoscopic Release of Chronic Resistant Plantar Fasciopathy

Plantar fasciopathy is the most common cause of plantar heel pain. No enough evidence in literature strongly supports the effectiveness of any specific treatment for such conditions. To assess the efficacy and safety of a modified surgical technique for endoscopic release of plantar fascia. A total of 40 feet in 40 patients with plantar fasciopathy for at least one year and resistant for at least two modalities of conservative treatment for six months were involved in this prospective study. All patients had been diagnosed clinically.The mean AOFAS preoperative score had improved from 51.36 to 89.44 after six months follow-up. While The VAS score dropped from 9 preoperative to 1. Eighty four (84%) of patients had satisfactory outcomes according to Roles and Madsuley criteria. No major complications were recorded. Endoscopic plantar fascia release could be a viable alternative for management of chronic resistant plantar fasciopathy.

Endoscopic Sphenopalatine Artery Cauterization in Refractory Hypertensive Epistaxis.

Epistaxis is a commonly occurring phenomenon which is defined as "bleeding from inside the nose" and often presents as an emergency. The management of epistaxis involves many factors with regard to the treatment and ultimate control of the condition. Each patient presenting with epistaxis should be well assessed clinically and managed accordingly. Endoscopic sphenopalatine artery cauterization is a safe, simple and effective procedure in the management of refractory epistaxis. Moreover, in view of minimal morbidity, higher success rate, shorter hospital stays and higher patient satisfaction, our current practice is to consider this treatment option in the management of cases not responding to conservative treatment modalities. A total of 11 patients (8 males and 3 females) underwent sphenopalatine artery cauterization during the study period. All patients were hypertensive and were refractory to treatment with general measures, anterior nasal packing and Foley catheter. The mean age of the study population was 58.36 and the range was 39-70years. The epistaxis was rapidly controlled in all patients without any intraoperative or postoperative complications. The follow up period was 60-90days. Strict control of hypertension was done throughout the follow up period. None of the patients developed epistaxis in the follow up period. The sphenopalatine artery cauterization technique using nasal endoscope was safe, simple, fast and effective with low rates of morbidity and complications for the management of refractory epistaxis. It was concluded that endoscopic sphenopalatine artery cauterization should be considered as an immediate second line treatment where conservative measures fail and it is proved to be of low morbidity and cost effective.

Effect of using Photobiomodulation, stabilization, and anterior repositioning splints on the pain level of subjects with temporomandibular joint disc displacement with reduction

Objective: was to evaluate the effect of four conservative treatment modalities on the pain level of patients withtemporomandibular joint (TMJ) anterior disc displacement with reduction (ADDwR). Material and Methods:100 subjects (64 females and 36 males) were selected, divided into four groups, 25 patients of each. Subjects ofGroup I have been treated with behavioral therapy. Subjects of Group II had been treated with Photobiomodulationtherapy (PBMT). Subjects of Group III had been treated by anterior repositioning splint (ARS). Subjects of GroupIV had been treated by a stabilization splint. The pain was evaluated by visual analog score (VAS) from 0 to 10.Statistical analysis was done using one-way ANOVA test for comparison between groups. Within each group, acomparison between baseline and after treatment was done using paired t-test (p<0.05). Results: There wasa statistical difference between the pain scores of the different groups after treatment (p < 0.05). Also, therewere statistical differences between all groups (p < 0.05) except that between group II and group III (p > 0.05).Conclusion: The use of stabilization splint and ARS are effective non-invasive methods for reducing the painlevel in the treatment of TMJ ADDwR cases. KEYWORDSAnterior repositioning splint; Disc derangement; Disc displacement; Low level laser therapy; Photobiomodulationtherapy; Stabilization splint; TMD.

ENDOSCOPIC RELEASE OF RESISTANT PLANTAR FASCIOPATHY

Background: Plantar fasciopathy is the most common cause of plantar heel pain. No enough evidence in literature strongly supports the effectiveness of any specific treatment for such conditions. Objective: To assess the efficacy and safety of a modified surgical technique for endoscopic release of plantar fascia. Patients and methods: A total of 29 feet in 25 patients with plantar fasciopathy for at least one year and resistant for at least two modalities of conservative treatment for six months were involved in this prospective study. All patients had been diagnosed clinically and the study was carried at the Department of Orthopedics, AL-Hussein University Hospital, Faculty of Medicine, Al-Azhar University in the period between December 2019 and September 2020. Results: The mean AOFAS preoperative score had improved from 51.36 to 89.44 after six months follow-up. While The VAS score dropped from 85 preoperative to 12.6. Eighty four (84%) of patients had satisfactory outcomes according to Roles and Madsuley criteria. No major complications were recorded. Conclusion: Endoscopic plantar fascia release could be a viable alternative for management of chronic resistant plantar fasciopathy.

Intentional replantation: A measure to save the natural tooth

Context: Intentional replantation (IR): is an accepted procedure in which a tooth is extracted and treated outside the oral cavity, then reinserted into its original socket, this technique can be useful for teeth that cannot be treated with conventional endodontic therapy (or) surgery. Aim: Preservation of natural dentitions is the primary (aim) of any conservative treatment modality, so IR is one of the techniques used to save the natural tooth. I treated thirty infected hopeless teeth for thirty patients. These cases cannot be treated with conventional endodontic therapy (or) surgery and the results were satisfactory. In these papers I reported four cases had been done according to the same principle (IR) but differ in simple things such as: (the patient complaint, type of crown filling, type of fixation of the tooth, and time of follow up). First case: A 23-years old male was referred to with a complaint of recurrent pain and discomfort in the mandibular right area. Clinically there was a sinus tract present, associated with the 1st right molar, the crown repair with a large amalgam filling, radiology showed there was per apical radiolucency and root canal filling with unsatisfactory obturation. When the patient selects IR and refused other options, so IR was planned. Clinical and radiograph follow-up 6 months postoperatively revealed no sign or symptoms of infection or inflammation and the tooth retain natural function. Second case: A 25-years old male, with a complaint of severe pain following the 2nd visit of retreated Root Canal Therapy to the right upper second premolar. The patient refused to continue endodontic treatment and wanted a solution to keep his tooth the other way, after a discussion about the options that help him to keep his tooth, he selects the I R option. So, IR was done followed by clinical examination 7 months postoperatively revealed no signs or symptoms of infection or inflammation. Third case: A 39-years old female, referred with a persistent dull pain at right upper teeth, clinical and radiological exam shown that there was apical lesion. I R planned after agreement of patient, post-operative follow up revealed no sign or symptom of infection or inflammation. Fourth case: A 20-years old female, referred a complaint of severe pain in the right mandibular molar, clinically there was a large carious lesion, the gum swollen, radiograph showed that there was an apical lesion around the apical root of 3rd molar. IR was done, after follow up the tooth was healthy and functions.

Assessment of Cerebral Autoregulation in the Perifocal Zone of a Chronic Subdural Hematoma.

The knowledge of conservative treatment modalities for a chronic subdural hematoma (CSDH) is still based on low-grade evidence. The purpose of this study was to evaluate the condition of the microcirculation and autoregulation in the perifocal CSDH zone for understanding of the mechanism of CSDH development. Cerebral microcirculation was evaluated in patients with the aid of brain perfusion computed tomography (PCT) within the first day. Perfusion parameters were assessed quantitatively in the cortex zone adjacent to the CSDH and in a similar zone of the contralateral hemisphere. The same PCT data were assessed quantitatively without and with use of a perfusion calculation mode excluding large-vessel voxels ("remote vessels" (RVs)) in the first and second methods, respectively. The first method of analysis of a similar zone in the contralateral hemisphere revealed significant increases in cerebral blood volume and cerebral blood flow (P<0.01) in comparison with normal values. Use of the second method with RVs showed no significant changes in perfusion parameters in microcirculatory blood flow in the cortex on the side contralateral to the hematoma. The persistence of microcirculatory blood flow perfusion reflects preservation of cerebral blood flow autoregulation in patients with a CSDH.

Paradigms in Complex Facial Scar Management.

The process of scar formation is a sequela of the healing following soft tissue injury extending to, or through, the reticular dermis. Scars, within the head and neck in particular, may be physically disfiguring with resultant psychosocial implications. Mitigation of excessive scar formation during the healing process following surgery, or in the setting of trauma, begins with meticulous soft tissue handling and reconstructive technique. The reconstructive surgeon's armamentarium must therefore include techniques that minimize initial scar formation and revision techniques that address unfavorable outcomes. With this in mind, this article reviews both conservative nonsurgical and surgical treatment modalities that mitigate scar formation or address mature scar formation.

Functional and Aesthetic Outcome of Fingertip Injuries' Management

Background: Fingertip injuries are the most commoninjuries that occur to the hand, accounting for 4.8 millionEmergency Department visits per year. Fingertip injuriesrequires immediate intervention to avoid any complicationsor deformities. Several therapeutic modalities have been usedfor treatment; either surgical or conservative treatment andeach of them has its own advantages and disadvantages.However, evidence is still lacking in the literature supportingeither surgical or conservative lines of treatment. The purposeof the present study is to compare functional and aestheticoutcomes between surgical and conservative treatment offingertip injuries.Methods: This prospective study included 50 patientswith Allen's type II and III of fingertip injuries divided intotwo groups; Group I included 20 patients treated surgicallyand Group II included 30 patients treated conservatively whichis further subdivided into subgroup I (Platelet Gel), subgroupII (Hyaluronic acid) and subgroup III (Fucidic acid).Results: The conservative treatment showed a significantimprovement regarding the sensory outcome, the range ofmotion, rate of complications, the aesthetic outcome and thepatients' satisfaction (p=0.002, 0.001, 0.021, 0.035, 0.026respectively). The platelet gel in the conservative treatmentshowed a significantly shorter time of healing compared toother modalities of conservative treatment (p=0.004) thus asignificant faster recovery and shorter time off-work (p=0.001).Conclusion: We concluded that the conservative treatmentprovides better functional and aesthetic outcome in treatingfingertip injuries. The use of platelet gel in fingertip injuriesis associated with decreased time of healing and early returnto work.

Combined Uterine Artery Ligation, Segmental Myometrial Resection and Intrauterine Balloon to Control Bleeding from Placenta Previa Accreta during Caesarean Section

Background: Morbidity attached placenta (MAP) remain a major surgical problem for obstetricians due to severe hemorrhage and its incidence had been continually increased due to increased rate of cesarean deliveries. Aim of the work: To evaluate the safety and efficacy of a conservative intervention for management of placenta accreta.Patients and methods: Forty-eight, pregnant females with a confirmed diagnosis of placenta previa accreta had been scheduled for elective cesarean delivery had been included. All females had been screened by full history taking, clinical examination, ultrasound and lab investigations. Blood loss, operative time, need for transfusion and need for other surgical interventions represented the main outcome and other complications were documented.RESULTS: The blood loss (ml) ranged between 850 to 1300 ml; the mean values were 1082.29±105.89 ml. The operative time ranged between 60 to 130 minutes; the mean values were 87.92±19.35 minutes. There was significant decrease of post-partum hemoglobin when compared to corresponding pre-partum values (9.29±0.76 vs 10.71±0.54 mg/dl respectively). Four patients [8.3%] need ICU admission, and nine patients [18.75%] need blood transfusion. However, no patients need further surgical intervention or developed DIC. In addition, no mortality had been reported in the current work. Conclusion: Combined uterine artery ligation, partial segmental myometrial resection and intrauterine balloon as a conservative treatment modality or placenta previa accreta is safe and effective

The Value of Digital Subtraction Angiography in Interlaminar Cervical Epidural Steroid Injections

Neck and upper extremity radicular pain is a common indication for ambulatory clinic visits for Chronic pain. By the time a patient to a Pain specialist, they have often exhausted all conservative treatment modalities including rest, heat, Nonsteroidal anti-inflammatory drugs, muscle relaxants and Physical therapy. These patients have often failed a trial of opioids as well and deemed not a candidate for surgery by a Spine surgeon.

MAGNETIC RESONANCE EVALUATION OF INVASIVE PLACENTA – OUR EXPERIENCE

Introduction: Placenta accreta (PA) includes various types of abnormal placentation in which chorionic villi attach directly to or invade he myometrium. There is a rising trend of placenta accreta owing to increased number of primary and repeat Caesarean sections. Accurate and timely identification of affected pregnancies allows optimal obstetric management to reduce maternal morbidity and mortality. The availability of conservative treatment modalities for the management of post partum hemorrhage arising from the same mandates the use of magnetic resonance imaging (MRI) to precisely evaluate the degree of placental invasion so as to further guide the treatment options. Materials and Methods: In two years observational cross sectional study, 18 pregnant females between age group 15-40 years were subjected to MRI pelvis and MRI findings were noted. Result : Placenta accrete vera was the most common type found in our study. Patients with placenta previa and previous Caesarean section were at highest risk. Intraplacental bands, heterogenous placenta, lumpy placental contour were the most commonly observed findings. Conclusion: MRI is very useful for accurate evaluation of placenta accreta particularly when USG findings are ambiguous or when there is a posterior placenta. There is increased incidence of placenta accreta with multiparity, placenta previa and history of previous Caesarean sections.

Conservative Versus Surgical Management of Fifth Metatarsal Avulsion Fractures

Fifth metatarsal avulsion fractures are among the most common fractures seen by foot and ankle surgeons. Studies have centered around classification systems, but debate continues regarding surgical versus conservative treatment modalities. The present study focused on quantifying the time for healing fifth metatarsal base avulsion fractures. Specifically, we compared healing time, displacement, and incidence of nonunion among surgically managed and conservatively managed avulsion fractures. Surgically managed patients underwent either open reduction with internal fixation or closed reduction with percutaneous fixation. Conservatively managed fractures were immobilized with a below-knee cast or pneumatic walking boot. Fifty-one patient records (51 feet) were retrospectively compared for basic demographics, smoking, and diabetes status, presence of peripheral neuropathy, Stewart classification, amount of displacement, rate of nonunion, and radiographic healing time. The groups did not differ significantly based on age, sex, or the remaining clinical characteristics including time to consolidation. However, among the 31 conservatively managed patients, 11 (35.5%) developed an asymptomatic nonunion versus none among the 20 patients treated surgically (p = .004). All patients were asymptomatic at 1 year. This study provides insight into the time required for fifth metatarsal avulsion fractures to heal or become asymptomatic. The surgical management of these fractures helped to eliminate the risk of nonunion and helped ensure a timely return to preinjury activity. We recommend surgical management of any fifth metatarsal avulsion fracture displaced >2 mm. Both patients and physicians should have realistic expectations when making decisions regarding treatment modalities for fifth metatarsal avulsion fractures.

Hemisection: A conservative approach for tooth preservation

Hemisection or root resection is a conservative treatment modality for cariously destructed, furcal involvement and failure of retreatment cases. Mandibular molars which are most commonly extracted due to caries and periodontal issues are the major standpoint for occlusion. Hemisection, a treatment modality provides a ray of hope to conserve the natural tooth structure and remove only the diseased portion followed by prosthetic rehabilitation. The present case report exhibits two cases of lower mandibular first molar where one root is resected, while preserving the remaining structure and promoting healing by placing autologous platelet rich fibrin(PRF) in the socket. Keywords: Hemisection, Furcation, Plateletrich fibrin.

Comparison of Kinesiotaping, Exercise and Subacromial Injection Treatments on Functionality and Life Quality in Shoulder Impingement Syndrome: A Randomized Controlled Study.

Disturbance of scapulohumeral rhythm has been shown to play a major role in subacromial impingement syndrome. Exercise, taping and subacromial injection are first ray conservative treatment modalities. We aimed to correct scapulohumeral rhythm with kinesio taping and exercise program via focusing on especially periscapular muscles not on glenohumeral structures to achieve scapulothorasic stabilization. Seventy five patients were divided into three groups randomly with different treatment modalities which are only exercise group (Group 1), kinesiotaping + exercise group (Group 2), and injection + exercise group (Group 3). Western Ontario Rotator Cuff Index (WORCI), Quick Disability of arm, shoulder, hand (Q-DASH), Constant- Murley Scores (CMS) were evaluated for each patient at the beginning, 15th and 60th days and compared in time and technique manner. Scores were analyzed statistically with One-way ANOVA and Chi-square tests. All the three groups had better results in short and long term follow ups as compared to initial admission. But in the second group 15th and 60th day results were superior to other groups significantly (p < 0,001). Most of recent studies using kinesio taping were focused on mechanical correction of humerus which will be an impaired treatment to correct the main cause of impingement. Not only mechanical correction of periscapular muscles and also stabilization of scapulae will help to gain scapulohumeral rhythm.

Location-based treatment of intracranial aneurysms in moyamoya disease: a systematic review and descriptive analysis

We conducted a systematic review of the literature to evaluate the efficacy of various treatment modalities for intracranial aneurysms (IA) in patients with moyamoya disease (MMD) based on anatomical location of IA. A comprehensive review of studies documenting single cases or series of MMD patients with concomitant IA was conducted. Aneurysms were classified into two primary anatomical categories: those of the Circle of Willis (CoW) and those of peripheral "moyamoya" collateral vessels. Conservative, endovascular, and open surgical treatment modalities and their outcomes between each anatomical subgroup were descriptively compared. A total of 124 studies consisting of 275 patients with 313 IA were included. Of all IA, 59.6% were located on CoW vessels, 33.7% on peripheral vessels, and 6.7% in "other" locations. Of all CoW IA, 87.2% treated with endovascular techniques had no or minimal deficit at follow-up as compared with 56.7% of those treated with open surgery. Ninety-five percent of patients with peripheral aneurysms treated with endovascular therapy had no or minimal deficit, in contrast to open surgery (69.6%). Of peripheral IA treated conservatively with or without revascularization, 65.7% had spontaneous resolution as compared with 12.0% IA of the CoW. Our results support the use of endovascular techniques for direct treatment of both CoW and peripheral IA. Aneurysms of peripheral vessels respond well to indirect treatment through surgical revascularization as opposed to CoW aneurysms. The quality of evidence is limited due to heterogeneity of included studies and IA management in MMD patients should be considered in a case-specific manne.

Conservative Management of de Quervain Stenosing Tenosynovitis: Review and Presentation of Treatment Algorithm.

Nonsurgical management of de Quervain disease relies mainly on the use of oral nonsteroidal antiinflammatory drug administration, splint therapy, and corticosteroid injections. Although the latter is most effective, with documented success rates of 61 to 83 percent, there exists no clear consensus pertaining to conservative treatment protocols conferring the best outcomes. This article reports on all present conservative treatment modalities in use for the management of de Quervain disease and highlights specific treatment- and patient-related factors associated with the best outcomes. A systematic search was performed using the PubMed database using appropriate search terms; two independent reviewers evaluated retrieved articles using strict inclusion and exclusion criteria. A total of 66 articles met the inclusion criteria for review, consisting of 22 articles reporting on outcomes following a single conservative treatment modality, eight articles reporting on combined treatment approaches, 13 articles directly comparing different conservative treatment regimens, and 23 case reports. A multimodal approach using splint therapy and corticosteroid injections appears to be more beneficial than either used in isolation. Although there exists some evidence showing that multipoint injection techniques and multiple injections before surgical referral may provide benefit over a single point injection technique and a single injection before surgery, corticosteroid use is not benign and should thus be performed with caution. Ultrasound was proven valuable in the visualization of an intercompartmental septum, and ultrasound-guided injections were shown to both be more accurate and confer better outcomes. Several prior and concurrent medical conditions may affect conservative treatment outcome. A Level I to II evidence-based treatment protocol is recommended for the optimal nonsurgical management of de Quervain disease.

Comparison of immediate response to four conservative treatment modalities for management of masticatory myalgia with limited mandibular movement: a retrospective study.

Conservative treatment modalities are recommended for managing masticatory myalgia in individuals with temporomandibular disorders. The aim of this study was to retrospectively review and compare the effectiveness of four conservative treatments: counseling and occlusal splint therapy, counseling and manipulation integrated with electrophysiotherapy, the combination of the two treatments, and counseling only. One hundred and sixty-eight patients who had myalgia with limited jaw movement were retrospectively observed in this study. Between January 2015 and December 2017, 63 patients received counseling and stabilization occlusal splint therapy (Group 1), 35 patients received counseling and manipulation integrated with electrophysiotherapy (Group 2), 33 patients received the combination of counseling, splint therapy, and manipulation integrated with electrophysiotherapy (Group 3), and 37 patients received counseling only (Group 4). All subjects were followed up for 12 weeks. The intensity of spontaneous pain, palpation pain, chewing pain in the masticatory muscles, and range of pain-free maximal mouth opening were recorded in the clinical assessments. Intragroup and intergroup differences were examined by using analysis of variance (ANOVA) and the Kruskal-Wallis test. Spontaneous pain in the masticatory muscles was relieved significantly in all groups at the 6-week visit (P < .05), and no significant difference was found among the groups (P > .05). Palpation pain was relieved significantly at the 9-week visit in the counseling + occlusal splint therapy group, counseling + manipulation + electrophysiotherapy group, and counseling + occlusal splint + manipulation + electrophysiotherapy group (P < .05). In the treatment group with counseling alone, significant palpation pain relief occurred at 12 weeks. Chewing pain was relieved significantly at the 6-week visit in the counseling + occlusal splint therapy group, counseling + manipulation + electrophysiotherapy group, and counseling + occlusal splint + manipulation + electrophysiotherapy group (P < .05), yet no significant difference compared to the baseline was observed in the counseling-only group (P > .05). A significant increase in the maximal range of pain-free mouth opening was observed at the 9-week visit in the counseling + occlusal splint therapy group, and at the 3-week visit in the counseling + manipulation + electrophysiotherapy group and counseling + occlusal splint + manipulation + electrophysiotherapy group (P < .05). Nevertheless, no significant change in the range of mouth opening was found throughout the follow-up period in the counseling-only group (P > .05). Each of the included treatment modalities relieved spontaneous pain and tenderness to palpation of the masticatory muscles during the follow-up intervals. Counseling alone did not help patients with chewing pain and limited mouth opening in the short term. Treatment protocols including counseling, occlusal splint therapy, and manipulation, integrated with electrophysiotherapy showed the best short-term outcomes for symptomatic improvement.

Unstable distal clavicle fractures (Neer Type II): A review of the complications and functional outcomes among treatment modalities.

Objectives: To perform a systematic review of the literature on unstable distal clavicle fractures in order to determine the preferable treatment method. Data sources: A literature search for articles on keywords “distal clavicle fracture treatment” and “Lateral end fracture of the clavicle” written in English and published between January 1990 and August 2015 was reviewed from the PubMed database. Study selection: The articles written in English and non-English articles with an English abstract were also included. A bibliographical review of the included articles was performed to find omitted studies. Studies dealing with non-union (pseudo-arthrosis) and arthroscopic methods were excluded. Open fractures, pediatric fractures, mid-shaft, medial clavicle fractures, and complicated cases were excluded. Non-English articles without an English abstract were excluded. Eighty-six articles representing 1812 surgeries were selected. Data extraction: The manuscripts were classified in accordance with their level of evidence and surgery type. All manuscripts were closely examined with regard to functional scores (including Constant scores, UCLA and ASES scores), union rates and complication rates. Data synthesis: The mean nonunion rate, complication rate, and mean functional scores were calculated for each treatment modality. The extracted data were accumulated and the mean rates were calculated to evaluate and compare different treatment modalities. The means of the groups were analyzed using analysis of variance (ANOVA) and the Bonferroni post hoc test. The pearson correlation coefficient was used to analyze whether a significant correlation exists between the parameters. Two-tailed hypothesis was considered in the analyses, and the significant differences were accepted if p value was .05 or less. SPSS 18.0 software for Windows (SPSS, Inc., Chicago, IL, USA) was used in the evaluation of statistical analyses. Results A total of ten types of treatment modalities was compared according to results of constant scores, union rates and complication rates. ANOVA test results showed significant differences between the groups with respect to union rate and complication rate (p=0.000 and p=0.000 respectively), while there were no statistically significant differences between the groups regarding to constant scores (p= 0.301). According to Bonferroni post hoc test the differences were caused by conservative treatment modalities in both union and complication rates. Regarding Pearson correlation test; there were no statistically significant correlation between constant scores with other scores (p=0.551, r=0.069 and p= 0.147, r= -0.168 for union rate and complication rate respectively). However, there were statistically significant correlation between union and complication rates (p=0.000, r=-0.408). Conclusions: There is no difference between the surgical treatment methods, the conservative treatment method was found to be statistically different (worse) than all other methods. When the treatment modalities were arranged according to highest results of constant scores, union rates and the lowest scores of complication rates ; the distal clavicle anatomic plate (precontoured plate) with /without CC sling and CC-sling(alone ) were the most preferable modalities according to benefited result relation. Thus, these techniques might be preferable. Keywords: Distal clavicle fracture, Lateral end clavicle fracture, Neer type II distal clavicle fracture, Unstable distal clavicle fracture.

Pituitary Apoplexy: A Comprehensive Review.

Pituitary apoplexy (PA) is a rare, usually vision-threatening and occasionally life-threatening entity. The exact incidence of PA in large series of pituitary adenomas is variable; however, it is more common in macroadenomas and nonfunctioning adenomas though it has been reported rarely in microadenomas. There are several well-known precipitating factors for PA including the use of anticoagulants, surgery, head trauma, pregnancy, etc. The typical clinical presentation is characterized by the near universal presence of headache with or without the following: visual disturbances, extraocular palsies, altered sensorium. MRI is the imaging modality of choice. Most patients have hormonal and/or electrolyte disturbances at the time of presentation which needs to be quickly corrected. Both conservative and surgical treatment modalities have been advised for the management of this condition. However, on the basis of the evidence available in the literature, the treatment should be individualized for each patient with PA. If conservative management is chosen, close clinical monitoring is necessary for early identification of deterioration. Surgery generally is through the trans-sphenoidal route. Most patients have a good recovery in visual function and extraocular palsy. There is some evidence in the literature that surgical intervention, when necessary, should be undertaken early as it is associated with better visual outcome. The majority of the patients will have residual hormonal deficits which will require prolonged hormone replacement therapy. There is a small but significant risk of recurrent PA in patients with residual tumors, especially, in those with large tumor residues. There is also a small risk of tumor recurrence following PA and hence all patients should undergo surveillance imaging periodically to detect the possible recurrence of tumor. In recent years, the mortality from PA has decreased significantly. A high index of suspicion and prompt multidisciplinary management will often lead to an overall good outcome.