Initial Nonoperative Treatment Research Articles

Functional Outcome and Patient Satisfaction After Primary vs Secondary Arthrodesis for Lisfranc Injuries: Toward a Single-Surgery Approach.

The choice between primary arthrodesis (PA) and open reduction and internal fixation (ORIF) for acute Lisfranc injuries remains contentious. Apart from primary treatment, arthrodesis is often used for treating chronic Lisfranc injuries, including patients in whom initial ORIF or nonoperative treatment failed. The aim of this study was to compare PA and secondary arthrodesis (SA) in terms of complications and functional outcome. A retrospective cohort study was conducted on trauma patients with Lisfranc injuries treated at a level 1 trauma center between July 1, 2010, and July 1, 2020. Selected patients were evaluated at the outpatient clinic and received a survey. Demographics, injury characteristics, management, complications, and patient-reported outcomes (American Orthopaedic Foot & Ankle Society midfoot score, Foot Function Index) were analyzed. Twenty-nine of 37 potential patients (78.4%; PA n = 11, SA n = 18) completed the survey with a median follow-up of 7.1 (PA) to 9.3 (SA) years (P = .01). The majority were female (n = 18, 62.1%); the mean age of PA patients was 57.1 years (SD 14.2) compared with 43.5 years (SD 17.1) in SA patients (P = .04). In the PA group, there was no infection, 100% union, and implants were removed in 5 of 11 patients. In the SA group, 11.1% (n = 2) developed infection, malunion rate was 11.1%, implants were removed in 33.3% (n = 6), and 22.2% required revision surgery. AOFAS was "good" in PA (77.7, SD 17.3) compared with rated "fair" in SA (67.1, SD 21.3, P = .19). FFI was better in PA (26.0, SD 26.2) than SA (37.6, SD 30.8, P = .32), which exceeded the minimally important clinical difference. Although this study was limited by sample size, the overall results suggest equivalent functional outcome, pain and treatment satisfaction in primary arthrodesis compared with secondary arthrodesis patients for treatment of Lisfranc injury.

Evaluation and Management of Glenohumeral Instability in Adolescent Patients: An Expert Consensus Statement.

Management of glenohumeral instability in the adolescent population can be both challenging and controversial. There are no current guidelines for optimal management of glenohumeral instability in this population (unidirectional or multidirectional), and the cutoff ages for transition to adult treatment are not known. To develop consensus-based guidelines for the management of glenohumeral instability in adolescents. Consensus statement. A 26-question, multiple-choice survey was developed after 2 rounds of iterations and was submitted to the orthopaedic surgeons of the Pediatric Research in Sports Medicine (PRiSM) Society. The survey comprised 3 sections-demographics, practice setting, and decision-making-and included cutoff ages and management in 5 specific case scenarios. Consensus-based guidelines were generated with 66% response agreement. An indication score was then applied to each response related to more aggressive management to determine if variables related to consensus (or lack thereof) could be identified. A total of 54 responses were returned. Of the respondents, 59% were from academic practice, 84% were pediatric orthopaedic fellowship trained, and 46% performed >25 shoulder instability cases per year. In the setting of first-time anterior shoulder dislocation, nonoperative treatment was preferred for boys aged <14 years and girls aged <13 years. Besides age, proximal humerus physeal status, injury mechanism, sport, and presence of bony injury affected treatment selection. The presence of a Bankart lesion was an indication for stabilization in first-time dislocations for contact athletes with a closing or closed physis, but not in patients with an open physis or noncontact injury mechanisms. For recurrent anterior shoulder dislocation, stabilization was preferred irrespective of physis status. Initial nonoperative treatment was preferred for multidirectional instability. In the setting of first-time anterior shoulder dislocation in patients with open physes, nonoperative treatment was preferred for boys <14 years and girls <13 years. Future multicenter prospective studies focusing on outcomes would help to validate current practice patterns, especially in scenarios for which no consensus was reached.

Comparison of outcome of early tangential excision with autografting versus interactive antimicrobial dressing in deep-partial thickness burn patients: A retrospective analysis

BackgroundThe relative effectiveness of early excision and autografting (EG) for deep-partial thickness burns needs to be updated through comparison to initial non-operative (INO) treatment using modern interactive antimicrobial (IA) dressings in a South-Asian burn patient population. ObjectiveTo compare the outcome of early tangential excision and autografting (EG) to initial non-operative (INO) treatment using interactive antimicrobial dressing. MethodsRecords of 106 adult burn survivors with predominantly deep-partial thickness thermal burns of TBSA ≤ 30 % were retrospectively reviewed (53 patients each in EG-arm and INO-arm). EG-arm patients underwent excision and autografting within 7 days. INO-arm patients, who had opted against surgical excision, received interactive antimicrobial dressing (hydrofiber with ionic silver). Outcomes measured include percentage of wound healed on days 14 and 21, days to complete wound healing, duration of hospital stay, complications (on 12 months’ follow-up) and patient satisfaction scores. Patients were analyzed as treated. ResultPatients in each arm had similar TBSA and demographic profiles. In EG-arm patients, 15–20 % of TBSA were grafted on 5.02 ± 0.71 post-burn day. Thirty percent of EG-arm patients required a second session of grafting for the remaining burn wound, which occurred on 6.873 ± 0.34 post-burn day. On the 21st post-burn day the EG-arm, compared to the INO-arm, had a higher percentage of wound epithelization (98.60 ± 4.03, versus 76.16 ± 7.02, P < 0.01), less days to complete healing (17.60 ± 5.83, versus 40.16 ± 9.09, P < 0.01), and shorter hospital stays (19.62 ± 6.85 days, versus 35.56 ± 7.77 days, P < 0.01). Twenty-five (47 %) INO-arm patients underwent delayed grafting on post-burn day 25.42 ± 0.49. The INO-arm suffered significantly more complications, such as hypertrophic scar, dyspigmentation and functional disability (P < 0.05). EG-arm patients were more satisfied than INO-arm patients (P < 0.01). ConclusionWe report superior outcomes in the early tangential excision and autografting-arm as compared to the initial non-operative treatment arm. The dogma of early excision and autografting remains valid despite significant advances in wound dressing materials.

Surgical and non-operative treatment of acute complicated diverticulitis in a COVID hospital

Surgical treatment of acute abdomen during the SARS-CoV-2 pandemic was accompanied by an extremely high mortality rate, however, only a few studies have presented the results of acute inflammatory complications of diverticular disease (AICDD).AIM: analysis of treatment of AICDD in a COVID-19 hospital.PATIENTS AND METHODS: the retrospective study included 78 patients with acute diverticulitis (AD) from a COVID hospital, confirmed by CT or intraoperative revision. Assessment of COVID pneumonia, comorbidities, organ dysfunction, CT findings, peritonitis, treatment methods, and in-hospital mortality among patients was performed.RESULTS: organ dysfunction of ≥ 1 point on the qSOFA scale was detected in 59.0% of the patients. According to CT data, abdominal distant gas was detected in 48 (61.5%) patients, and pericolic gas in 14 (17.9%) patients. Segmental colon resection was performed in 60 (76.9%) patients, laparoscopic lavage (LL) of the abdominal cavity — in 3, non-operative treatment (NOT) with drainage of fluid collections — in 6, and only NOT in 10 patients. Most patients with distant or pericolic gas were operated on within an average time of 1 [0; 3.5] hours after admission. Diffuse peritonitis was detected during surgery in 45 (75%) of them. After resection, organ dysfunction of ≥ 2 points on the SOFA scale developed or progressed in 52 (86.7%) patients. The overall mortality rate was 48.7%, and the postoperative mortality was 63.3%. All patients (n = 38) died after segmental colon resection. Successful NOT was achieved in 4 patients with pericolic gas and 3 patients with distant gas.CONCLUSION: surgery for AICDD in patients with COVID-19 is associated with extremely high mortality, therefore, in the absence of obvious signs of diffuse peritonitis, initial non-operative treatment may be life-saving.

Towards a tailored approach for patients with acute diverticulitis and abscess formation. The DivAbsc2023 multicentre case–control study

BackgroundThis multicentre case–control study aimed to identify risk factors associated with non-operative treatment failure for patients with CT scan Hinchey Ib-IIb and WSES Ib-IIa diverticular abscesses.MethodsThis study included a cohort of adult patients experiencing their first episode of CT-diagnosed diverticular abscess, all of whom underwent initial non-operative treatment comprising either antibiotics alone or in combination with percutaneous drainage. The cohort was stratified based on the outcome of non-operative treatment, specifically identifying those who required emergency surgical intervention as cases of treatment failure. Multivariable logistic regression analysis to identify independent risk factors associated with the failure of non-operative treatment was employed.ResultsFailure of conservative treatment occurred for 116 patients (27.04%). CT scan Hinchey classification IIb (aOR 2.54, 95%CI 1.61;4.01, P < 0.01), tobacco smoking (aOR 2.01, 95%CI 1.24;3.25, P < 0.01), and presence of air bubbles inside the abscess (aOR 1.59, 95%CI 1.00;2.52, P = 0.04) were independent predictors of failure. In the subgroup of patients with abscesses > 5 cm, percutaneous drainage was not associated with the risk of failure or success of the non-operative treatment (aOR 2.78, 95%CI − 0.66;3.70, P = 0.23).ConclusionsNon-operative treatment is generally effective for diverticular abscesses. Tobacco smoking's role as an independent risk factor for treatment failure underscores the need for targeted behavioural interventions in diverticular disease management. IIb Hinchey diverticulitis patients, particularly young smokers, require vigilant monitoring due to increased risks of treatment failure and septic progression. Further research into the efficacy of image-guided percutaneous drainage should involve randomized, multicentre studies focussing on homogeneous patient groups.Graphical abstract

No Differences in Clinical, Functional, or Patient-Reported Outcomes Following Trial of Nonoperative Management Before Open Reduction and Internal Fixation of Humeral Shaft Fractures.

To test the hypothesis that primary osteosynthesis of humeral shaft fractures may lead to more favorable clinical, functional, and patient-reported outcomes than fixation following a trial of nonoperative management. Retrospective cohort review. Academic level I trauma center. Adult patients who presented with humeral shaft fractures and ultimately underwent open reduction and internal fixation (ORIF) from May 2011 to May 2021. Patients who underwent ORIF within 2 weeks of injury were grouped into the primary osteosynthesis cohort, and patients who underwent ORIF >4 weeks from the date of injury were grouped into the trial of nonoperative cohort. Postoperative complications, elbow arc of motion, time to radiographic union, and patient-reported outcomes were investigated and compared between the primary osteosynthesis and trial of nonoperative management cohorts. One hundred twenty-seven patients fit the study criteria, 84 underwent primary osteosynthesis and 43 trialed initial nonoperative treatment. No differences were found in patient demographics between the primary osteosynthesis and trial of nonoperative management cohorts, including age (53 ± 19 vs. 57 ± 18; P = 0.25), sex (39% vs. 44% male, 61% vs. 56% female; P = 0.70), and Body Mass Index (BMI) (30 ± 6 vs. 32 ± 9; P = 0.38). The average time to operative intervention in the primary osteosynthesis group was 4 days (0-14 days) and 105 days (28-332 days) in the trial of nonoperative treatment group ( P < 0.01). No differences were found with regard to intraoperative blood loss, total operative time, time to radiographic union (determined using the Radiographic Union Scores for Humeral scoring system), or overall complication rates, including primary and secondary radial nerve injuries ( P = 0.23 and 0.86, respectively). Patients reported similar patient-reported outcomes measurement information system pain interference ( P = 0.73), depression (D) ( P = 0.99), and physical function ( P = 0.66) scores at their 6-month postsurgical follow-up visits. Patients who attempted a trial of nonoperative management for humeral shaft fractures before ORIF had similar clinical, functional, and patient-reported outcomes as those who underwent primary osteosynthesis. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Higher Age is Associated with Lower Likelihood of Conversion to Surgery after Primary Nonoperative Treatment for Osteochondral Lesions of the Talus.

The first line of treatment for osteochondral lesions of the talus (OLT) is nonoperative. To date, there is limited evidence on risk factors that may influence conversion to surgery after primary nonoperative treatment for symptomatic OLTs. The aim of this study was therefore to identify risk factors for conversion to surgery after initial nonoperative treatment of OLTs. For this cohort study, patients with a primary OLT who were nonoperatively treated for at least 6 months between 1990 and 2020 were included. Univariable Cox regression analysis, resulting in hazard ratios (HRs), on the primary outcome (i.e. conversion to surgery after initial nonoperative treatment) was performed for potential risk factors. The following risk factors were analyzed: gender, age, body mass index (BMI), numeric rating scale (NRS), lesion size (depth, sagittal length, coronal length, volume, surface), lesion morphology (presence of fragments and presence of cysts), lesion location (medial/central/lateral), congruency of the ankle joint and trauma in history. Data imputation was conducted according to the multiple data principle with pooling. Forty-two patients with primary OLTs were included in this study: 23 (55%) males and 19 (45%) females with a mean age of 39.1 (SD: 14.2). The median overall follow-up time was 66 months (range: 7-188). Around 23% of the patients had a conversion to surgery at the median observation time. The Kaplan-Meier analysis revealed a survival rate of 93% (95% confidence interval [CI]:84-100), 90% (95% CI: 81-99), and 77% (95% CI: 63-91) at 1, 2, and 5 years after the initiation of treatment, respectively. After performing the COX regression analysis, age was the sole risk factor significantly associated with conversion to surgery with an HR of 0.93 (95% CI: 0.87-0.99). The different HRs for all other risk factors were as follows: gender: 0.33 (95% CI: 0.08-1.34), BMI: 0.87 (95% CI 0.76-1.01), depth: 0.97 (95% CI: 0.79-1.18), coronal length: 1.19 (95% CI: 0.97-1.44), sagittal length: 0.98 (95% CI: 0.87-1.12), surface area: 1.17 (95% CI: 0.41-3.31), volume: 0.96 (95% CI: 0.24-3.91), presence of fragments: 4.17 (95% CI: 0.84-20.61). For primary OLTs, 77% of the patients were successfully treated nonoperatively at a median follow-up of 66 months without the need for a surgical intervention. Survival rates of 93%, 90%, and 77% were found at 1, 2, and 5 years after the initiation of treatment, respectively. We found that a higher age at the moment of diagnosis was significantly associated with a lower likelihood of conversion to surgery with a 7% decrease of likelihood each year the patient is older at the moment of diagnosis. The findings of this study are clinically relevant as it ameliorates the quality of the shared decision-making process between the patient and the treating team as we can advise OLT patients at a higher age with tolerable symptomatology that there is a relatively lower risk of conversion to surgery.

Outcomes >30 Years After Initial Nonoperative Treatment of Anterior Cruciate Ligament Injuries

Background: It is unclear how anterior cruciate ligament (ACL) reconstruction (ACLR) affects the development of osteoarthritis (OA). This uncertainty is partly caused by the lack of long-term studies on ACL injuries treated primarily without reconstruction and the underreporting of symptomatic OA. Purpose: To determine (1) the knee function, symptoms, and activity level, as well as the presence of radiographic and symptomatic OA; (2) how these clinical outcomes have changed over time; and (3) the frequency of subsequent knee surgeries after the index ACL injury in a cohort of patients with ACL injuries treated primarily without reconstruction. Study Design: Case series; Level of evidence, 4. Methods: A total of 100 patients underwent initial nonoperative treatment >30 years ago (mean, 33.2 ± 1.4 years). Of these, 81 patients (mean age, 59 ± 8 years) completed the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Scoring Scale, and Tegner Activity Scale. Seventy-three patients underwent radiography to evaluate tibiofemoral and patellofemoral OA in the ACL-injured knee. Patients only underwent late ACLR if they experienced insufficient knee stability. Results: At 33 years after the ACL injury, the KOOS Activities of Daily Living subscore was better than population-based reference values, but scores were similar for the remaining KOOS subscales. Furthermore, 65% of patients had a good or excellent Lysholm score (≥84 points). The Tegner score decreased 4 points from before the injury to 33-year follow-up (P < .001). Most patients (75%) had evidence of radiographic tibiofemoral and/or patellofemoral OA, but only 38% were classified as having symptomatic OA (defined as radiographic OA in combination with a symptomatic knee according to cutoffs on the KOOS). Approximately 50% underwent meniscal surgery, and 29% subsequently underwent ACLR for recurrent instability. There were 2 patients who underwent total knee replacement. Conclusion: Despite a high prevalence of radiographic OA, patients achieved acceptable subjective knee function and had a relatively low prevalence of symptomatic OA at >30 years after an ACL injury when an initial nonoperative treatment strategy was employed.

Outcomes of initial nonoperative treatment of traumatic full-thickness rotator cuff tears

IntroductionNon-surgical management of chronic, degenerative rotator cuff tears (RCT) can be an effective treatment strategy, but there is limited evidence to support conservative treatment for acute, traumatic RCTs. The objective of this study is to assess clinical outcomes and predictors of treatment success for patients with traumatic RCTs who elected for initial non-operative treatment. MethodsPatients from a single institution were retrospectively identified using diagnostic codes for traumatic RCT followed by confirmed initial treatment with at least 2 months of physical therapy. Exclusion criteria included surgery within 2 months of injury and greater than grade I fatty infiltration on MRI. At minimum 2-year follow-up, patients were contacted by phone to collect interval surgical history and standardized patient reported outcomes. All those who had surgical treatment and those with satisfaction ratings of “moderately dissatisfied” and “very dissatisfied” were considered to have failed physical therapy. ResultsFollow-up outcomes were obtained in forty of 49 patients (82%) with an average follow-up time of 4.2 years. Nine RCTs (22%) were small (< 1cm), 22 (54%) were medium (>1 and < 3cm), and 9 (22%) were large (> 3 cm and < 5cm). Grade I fatty infiltration was seen on 25% (n=10) of MRIs. Eighteen patients (45%) underwent rotator cuff repair following an average 6 months (R: 3-12) of nonoperative treatment. In total, 23 of 40 patients (58%) were determined to have failed nonoperative treatment. Patients with multiple tendons torn were more likely to fail conservative management (p=0.014). Tear size and retraction were not significantly different between patents who had surgery and those who did not. Patients who underwent surgical management had 83% satisfaction rate at final follow-up compared to 55% satisfaction for patients who had no surgery (p=0.054). There was no statistical difference in the ASES (American Shoulder and Elbow Surgeons score) and VAS (Visual Analog Scale) between these groups. While patients who had surgery had a higher mean SANE (Single Alpha Numeric Evaluation) (86.3 vs. 75.1; p=0.041), this difference was below the previously established minimally clinically important difference. ConclusionNon-operative treatment remains a viable option for certain patients with traumatic RCTs; however, the results of our study demonstrate a considerable early failure rate. This study further supports historical literature demonstrating reliably successful outcomes with surgical treatment of acute, traumatic RCTs. Level of EvidenceLevel IV; Case Series; Treatment Study

Needling and Lavage in Rotator Cuff Calcific Tendinitis: Ultrasound-Guided Technique.

Rotator cuff calcific tendinitis (RCCT) is a commonly occurring disease, with a prevalence of up to 42.5% in patients with shoulder pain1,2. RCCT is characterized by hydroxyapatite deposits in the tendons of the rotator cuff and is considered a self-limiting disease that can be treated nonoperatively3. However, in a substantial group of patients, RCCT can have a very disabling and long-lasting course1,4, requiring additional treatment. Ultrasound-guided percutaneous needling and lavage (i.e., barbotage) is a safe and effective treatment option for RCCT5. In the present article, we focus on the 1-needle barbotage technique utilized in combination with an injection of corticosteroids in the subacromial bursa. It must be emphasized that symptomatic RCCT should be confirmed before barbotage is performed. Therefore, we recommend a diagnostic ultrasound and/or physical examination prior to the barbotage. Barbotage is performed under ultrasound guidance with the patient in the supine position. After sterile preparation and localization of the calcified deposit(s), local anesthesia in the soft tissue (10 mL lidocaine 1%) is administered. Next, the subacromial bursa is injected with 4 mL bupivacaine (5 mg/mL) and 1 mL methylprednisolone (40 mg/mL) with use of a 21G needle. The deposit(s) are then punctured with use of an 18G needle. When the tip of the needle is in the center of the deposit(s), they are flushed with a 0.9% saline solution and the dissolved calcium re-enters the syringe passively. This process is repeated several times until no more calcium enters the syringe. In the case of solid deposits, it may not be possible to aspirate calcium; if so, an attempt to fragment the deposits by repeated perforations, and thus promote resorption, can be made. Postoperatively, patients are instructed to take analgesics and to cool the shoulder. RCTT can initially be treated nonoperatively with rest, nonsteroidal anti-inflammatory drugs, and/or physiotherapy3. If the initial nonoperative treatment fails, extracorporeal shockwave therapy (ESWT), corticosteroid injections, and/or barbotage can be considered8. In severe chronic recalcitrant cases, arthroscopic debridement and/or removal can be performed as a last resort. Both barbotage and ESWT result in a reduction of calcific deposits, as well as significant pain reduction and improvement of function8. No standard of care has been established until now; however, several prior meta-analyses concluded that barbotage is the most effective treatment option, with superior clinical outcomes after 1 to 2 years of follow-up9-11. No difference in complication rates has been reported between the various minimally invasive techniques. The purpose of barbotage is to stimulate the resorption process, which is promoted by the perforation of the deposits. Clinical outcomes are not associated with the success of the aspiration7,12. Patients with ≥1 larger deposit show greater improvement following barbotage than patients with small deposits12, in contrast with ESWT, in which larger deposits have been associated with worse outcomes. The inferior outcome of barbotage in patients with small deposits remains the subject of debate, but outcomes may be confounded by the fact that patients with smaller deposits might be less symptomatic at baseline and are therefore less likely to demonstrate improvement4. In the first weeks after barbotage, there is generally a substantial reduction in symptoms. Symptoms can recur at around 3 months, presumably because the effect of the corticosteroids is temporary5. After 6 months and 1 year, patients show substantial improvement in pain, shoulder function, and quality of life, with results superior to those shown for subacromial injections and ESWT9,10,13,14. At 5 years postoperatively, there are no significant differences in outcomes between barbotage and subacromial injections15. This may demonstrate a self-limiting course in the long term. Good candidates for barbotage are those with RCCT who have ≥1 large calcific deposit.If a patient has a solid deposit, the physician can gently rotate and repeatedly puncture the deposit to promote disaggregation and fragmentation.Barbotage generally results in adequate pain relief and functional improvement even in patients in whom calcium deposits cannot be aspirated12. SAI = injection in the subacromial bursaNSAIDs = nonsteroidal anti-inflammatory drugs.

Discussion to: Lung resection after initial nonoperative treatment for non–small cell lung cancer

Discussion to: Lung resection after initial nonoperative treatment for non–small cell lung cancer

Lung resection after initial nonoperative treatment for non–small cell lung cancer

ObjectivesThe study objectives were to assess the outcomes of lung resection in patients with non–small cell lung cancer previously treated with nonoperative treatment and to identify prognostic factors associated with survival. MethodsPatients who underwent surgery (2010-2022) after initial nonoperative treatment at a single institution were identified from a prospectively maintained database. Exclusion criteria included metachronous cancer, planned neoadjuvant therapy, and surgery for diagnostic or palliative indications. Cox models were constructed for overall survival and event-free survival. Survival of patients with stage IV disease was compared with survival of a nonstudy cohort who did not undergo surgery. ResultsIn total, 120 patients met the inclusion criteria. Initial clinical stage was early stage in 16%, locoregionally advanced in 25%, and metastatic in 59% of patients. The indication for surgery was recurrence in 18%, local persistent disease in 23%, oligoprogression in 22%, and local control of oligometastatic disease in 38% of patients. Grade 3 or greater complications occurred in 5% of patients; 90-day mortality was 3%. Three-year event-free survival and overall survival were 39% and 73%, respectively. Male sex and lymphovascular invasion were associated with shorter event-free survival and overall survival; younger age and prior radiation therapy were associated with shorter overall survival. Patients with stage IV disease who received salvage lung resection had better overall survival than similar patients who received subsequent systemic therapy and no surgery. ConclusionsIn this selected, heterogeneous population, lung resection after initial nonoperative treatment for non–small cell lung cancer was safe. Surgery as local consolidative therapy was associated with encouraging outcomes and should be considered for these patients.

Association of Periprosthetic Fibula Fracture With Knotless Suture Button (TightRope) Fixation for Ankle Syndesmosis in Elite Athletes

Background: Suture button fixation is frequently used to stabilize the distal tibiofibular syndesmosis in athletes sustaining an isolated ligamentous syndesmosis injury. Purpose: To report on a series of periprosthetic fibula fractures adjacent to the lateral suture button after a subsequent unrelated ankle injury or progressive stress injury after initial ankle syndesmosis stabilization using the knotless TightRope (Arthrex). Study Design: Case series; Level of evidence, 4. Methods: Eight elite athletes with periprosthetic fibula fractures and stress injuries around the lateral suture buttons were evaluated. In all athletes, the knotless TightRope had been used to stabilize an isolated ligamentous ankle syndesmotic injury, after which all patients recovered and returned to professional sports at their preinjury level. The athletes subsequently developed an acute fibula fracture or a fibula stress fracture related to the 3.7-mm drill hole in the fibula adjacent to the lateral suture buttons after a mean of 14.1 months (range, 5-29 months). The management of these complications was analyzed. Results: Five athletes sustained a periprosthetic fibula fracture in the form of undisplaced spiral Weber B injuries after a subsequent, unrelated injury. Poor healing response was noted with initial nonoperative treatment for the first 2 athletes, and surgical intervention was performed with successful union of the fracture and return to sports. The subsequent 3 athletes had early surgery with uneventful recovery. Another 3 athletes developed stress injuries adjacent to the fibula suture button without a history of acute trauma. In 2 of the 3 athletes, the position of lateral suture buttons was in the anterior third of the fibula. Initial nonoperative management yielded poor healing response, and subsequent surgical intervention was required to enable healing and return to sports. Conclusion: Nonoperative management of fractures adjacent to the fibula suture button of a knotless TightRope may lead to a delay in union. Therefore, early surgical intervention should be considered in elite athletes, whose return-to-sports time is critical. Care is needed to ensure that the fibula hole for the suture button is centrally located because the eccentric placement of the fibula hole in the anterior third of the fibula may contribute to the development of a stress reaction or stress fracture. Surgical intervention for a periprosthetic fibula stress fracture leads to satisfactory resolution of symptoms.

Diagnosis and Management Controversies Illustrated by an Uncommon Case of Postpartum Pubic Symphysis Diastasis

Pubic symphysis diastasis is a complication of pregnancy that can lead to prolonged recovery, persistent pain, and functional disability if managed inappropriately. There is a lack of universally accepted clinical guidelines with regards to the timeframe and defect criteria for surgical management, which contributes to delayed care resulting in increased surgical complexity and subsequent impairments in functionality and quality of life. The current standard of care utilizes non-operative measures exclusively for separations measuring less than 2.5 cm correlating to symphyseal ligament sparing. Surgical interventions are typically reserved for severe cases or those resistant to initial non-operative treatment. Non-surgical methods have been attempted for 4–6 weeks, even in severe cases, with patients still requiring eventual surgery. We herein report an uncommon case of pubic symphysis diastasis measuring 5.5 cm and the successful implementation of non-surgical management to demonstrate the need for updated standardized treatment guidelines. The defect in this case was treated with early application of a pelvic binder resulting in anatomic alignment and full resolution of pain within 3 months, and full return to activity within 6 months. In conclusion, the establishment of management guidelines for pubic symphysis is recommended, including the use of non-surgical management early in the patient recovery process and in cases with diastasis greater than 2.5 cm. This treatment strategy may decrease morbidity, recovery time, and complications in affected patients.

High prevalence of associated intra-articular injuries with increasing time period from anterior cruciate ligament injury to reconstruction, even in apparent copers

BackgroundIt still unclear whether copers may bear the same time-sensitive risk of intra-articular injury as non-copers. The objectives were to investigate the clinical characteristics of copers and non-copers that have sustained an anterior cruciate ligament (ACL) injury, and to examine and compare the intra-articular pathologies in delayed ACL reconstruction (ACLR) in copers and noncopers. MethodsPatients who sustained ACL injury while participating in high-performance sports and opted for non-operative treatment were enrolled in this study. Depending on the occurrence of the knee giving way, patients were classified into copers and noncopers. Clinical characteristics were compared between the two groups. Additionally, intra-articular injuries were evaluated for those who eventually underwent delayed ACLR. Results11 of the 75 patients (14.7%) were classified as copers. No major differences were found in the clinical characteristics between groups. Following the initial non-operative treatment, 67 patients underwent delayed ACLR. When examining intra-articular abrasions at the time of surgery, non-copers who continued sports activities for 3 to 12 months exhibited a significantly higher rate of injury as opposed to their coper counterparts. However, the difference in the prevalence of intra-articular lesions between the two groups in patients who continued to play sports for at least 12 months before surgery was nominal. ConclusionThe rate of copers was relatively low in patients who resumed playing high-level sports after ACL injury. Additionally, even in copers, those who continued sports activities for more than 12 months had comparably high prevalence of intra-articular injuries with noncopers. Study designRetrospective case-control study; Level of evidence, 3.

Non-Operative Treatment of Tibial Tubercle Fractures: Who is at Risk for Failure?

Introduction: Given the relative rarity of tibial tubercle fractures and the high proportion that undergo surgical treatment, there is little data on non-operative management of these injuries. Some patients that are initially treated non-surgically may ultimately require operative intervention. The purpose of this study was to identify risk factors for failed non-operative management of tibial tubercle fractures.Methods: This retrospective comparative study included patients younger than 18 years that underwent initial non-operative treatment of a tibial tubercle fracture at six tertiary children's hospitals. Those that underwent primary surgical intervention were excluded. Demographic, radiographic, and clinical data were reviewed. Conversion to surgical fixation was considered a failure of non-operative treatment. Univariable analysis was followed by multivariate regression to adjust for confounders.Results: A total of 136 patients were included, of which 19.1% failed non-operative treatment and subsequently underwent surgery. The median age of patients that ultimately required surgery was 14.0 y [IQR (interquartile range) 2.5 y] compared to 12.0 y (IQR 2.0 y) for those that were successfully managed without surgery. Non-operative treatment failed in 7.8% of Ogden type I fractures, 66.7% of type II, 81.8% of type III, 35.7% of type IV, and 7.1% of type V (p<0.001). After adjusting for confounders, including weight and initial weight-bearing status, each year of increasing age raised the odds of failure by 1.9 (95% CI 1.2-3.0, p=0.006). Additionally, Ogden type II fractures had 23.4 times higher odds than type I (95% CI 2.1-260.8, p=0.01). Ogden type III fractures had 36.3 times higher odds of failing non-operative treatment than type I (95% CI 4.2-315.4, p=0.001).Conclusion: In this study of patients with a tibial tubercle fracture initially treated non-operatively, 19.1% ultimately underwent surgery. Increasing age and Ogden type II and III fracture classification were associated with failure of non-operative management. These results may help guide decision-making regarding surgical versus non-surgical treatment.Significance: There is little data on non-operative treatment of tibial tubercle fractures. This study identifies risk factors for failure of non-operative treatment and may aid clinical decision-making.

Major Increase in Incidence of Pediatric ACL Reconstructions From 2005 to 2021: A Study From the Norwegian Knee Ligament Register

Background: The incidence of pediatric and adolescent anterior cruciate ligament reconstruction (ACLR) is increasing in several countries. It is uncertain whether this trend applies to countries that traditionally prefer an initial nonoperative treatment approach whenever possible, like Norway. Nationwide, long-term patient-reported outcomes and revision rates after ACLR in the pediatric population are also lacking. Purpose: To determine the incidence of pediatric ACLR in Norway since 2005, as well as to detect trends in surgical details and describe patient-reported outcomes up to 10 years after ACLR. Study Design: Descriptive cohort study. Methods: This study is based on prospectively collected data on girls ≤14 years and boys ≤16 years, registered in the Norwegian Knee Ligament Register at the time of their primary ACLR, between 2005 and 2021. The main outcome was the incidence of ACLR, adjusted to the corresponding population numbers for each year. The time trend was analyzed by comparing the mean of the first and last 3-year period (2005-2007 and 2019-2021). Patient-reported outcomes were assessed using the Knee injury and Osteoarthritis Outcome Score preoperatively and at 2, 5, and 10 years postoperatively. Results: A total of 1476 patients (1484 cases) were included, with a mean follow-up of 8.1 years (range, 1-17). The incidence of pediatric ACLRs per 100,000 population increased from 18 to 26, which corresponds to an increase of 40% for boys and 55% for girls. Concurrent meniscal procedures increased significantly from 45% to 62%, and the proportion of meniscal repairs increased from 19% to 43% when comparing the first and last time period. The mean Knee injury and Osteoarthritis Outcome Score values for the Sport and Recreation and Quality of Life subscales were between 72 and 75 at the 2-, 5- and 10-year follow-up. The 5-year revision rate was 9.9%. Conclusion: There was a major increase in incidence of pediatric ACLR in Norway during the study period. There was a shift in the approach to concomitant meniscal procedures from resection to repair, with more than a doubling of the proportion of meniscal repairs. Patient-reported outcomes revealed long-lasting reduced knee function.

Patients Aged >50 Years With Anterior Shoulder Instability Have a Decreased Risk of Recurrent Dislocation After Operative Treatment Compared With Non-Operative Treatment

To compare the clinical outcomes of operative and nonoperative management, identify risk factors for recurrent instability, and identify risk factors for progression to surgery after failed nonoperative management for patients with first-time anterior shoulder dislocation after the age of 50 years. An established geographic medical record system was used to identify patients who experienced a first-time anterior shoulder dislocation after the age of 50 years. Patient medical records were reviewed to identify treatment decisions and outcomes of interest, including rates of frozen shoulder and nerve palsy, progression to osteoarthritis, recurrent instability, and progression to surgery. Outcomes were evaluated using Chi-square tests and survivorship curves were generated using Kaplan-Meier methods. A Cox model was developed to evaluate for potential risk factors of recurrent instability and progression to surgery after an initial trail of at least 3 months of nonoperative treatment. 179 patients were included with a mean follow-up of 11 years. 14% (n= 26) underwent early surgery within 3 months and 86% (n= 153) were initially treated nonoperatively. Mean age (59 years), was similar for both groups, but those that underwent early surgery had an increased rate of full-thickness rotator cuff tears (82% vs 55%; P= .01), labral tears (24% vs 8.0%; P= .01), and humeral head fracture (23% vs 8.5%; P= .03). When comparing the early surgery group to the nonoperative group, there were similar rates of persistent moderate-severe pain (19% vs 17%; P= .78) and frozen shoulder (8 vs 9%, respectively; P= .87) at final follow-up. Although nerve palsy (19% vs 8%; P= .08) and progression to osteoarthritis (20% vs 14%; P= .40) were more common in surgical patients, they experienced lower rates of recurrent instability after surgical intervention (0% vs 15%; P= .03) compared to nonoperatively treated patients. Increasing number of instability events prior to presentation was the greatest risk factor for recurrent instability (HR 232; P < .01). Fourteen percent (n= 21) failed initial nonoperative treatment and proceeded to surgical intervention at an average of 4.6 years after the initial instability event, and the greatest risk factors for progression to surgery were recurrent instability (HR 3.41; P < .01). Although the majority of patients >50 years that experience ASI are treated nonoperatively, those that require surgery tend to have more significant injury pathology, a lower risk of recurrent instability after surgery, but a higher progression to osteoarthritis compared to patients that do not require surgical intervention. There was no difference in pain severity at final follow-up, rates of frozen shoulder or nerve palsy between patients who underwent initial nonoperative treatment after instability and those who underwent surgery. A history of multiple instability episodes prior to presentation was the greatest predictor of recurrent instability and failure of nonoperative treatment and progression to surgery. Level III, retrospective cohort study.

The Utility of Routine Follow-up Radiographs in the Nonoperative Management of Proximal Humerus Fractures in Patients 65 Years and Older.

Whereas prior studies have aimed to define the utility of routine radiographs for the closed treatment of upper extremity fractures, it remains uncertain whether routine radiographs influence management decisions for nonoperative treatment of proximal humerus fractures (PHFs). The purpose of this investigation was to assess the utility of routine radiographic monitoring of closed PHFs in elderly patients initially indicated for nonoperative treatment. We identified all patients 65 years and older who had a PHF from 2016 to 2019. We excluded cases of pathologic fractures or peri-prosthetic fractures, nonunion, malunion, cases with insufficient follow-up, and cases for which surgery was indicated either in the emergency department or at the first orthopedic visit. After applying these exclusion criteria, 402 cases remained. We recorded baseline demographics and fracture descriptions and noted any conversion to operative treatment after the initial office visit. Two-part fractures were most common (56%). Of the 402 fractures indicated for nonoperative treatment, 21 (5%) were converted to operative management during the follow-up period. Nine fractures (2%) were converted to operative management within 30 days of the first office visit. Eight cases (2%) were converted to operative treatment more than 120 days after the initial office visit: 6 due to nonunion and 2 due to posttraumatic arthritis. For patients 65 years and older who undergo initial nonoperative treatment of a PHF, routine follow-up radiographs do not appear to alter management decisions. Given the risk and cost associated with routine radiographs, surgeons should consider forgoing these images in the absence of clinical concern. [Orthopedics. 2023;46(4):e244-e248.].

Arthroscopic Lysis of Adhesions for the Stiff Total Knee Arthroplasty.

Arthroscopic lysis of adhesions is a treatment option for patients with painful, stiff knees as a result of arthrofibrosis following knee arthroplasty, in whom prior manipulation under anesthesia (MUA) has failed. Typically, nonoperative treatment in these patients has also failed, including aggressive physiotherapy, stretching, dynamic splinting, and various pain-management measures or medications. Range of motion in these patients is often suboptimal, and any gains in flexibility will likely have hit a plateau over many months. The goal of performing lysis of adhesions is to increase the range of motion in patients with knee stiffness following total knee arthroplasty, as well as to reduce pain and restore physiologic function of the knee, enabling activities of daily living. This is a straightforward surgical technique that can be performed in a single stage. The preoperative range of motion is documented after induction of general anesthesia. The procedure begins with the establishment of standard medial and lateral parapatellar arthroscopic portals. A blunt trocar is introduced into the knee, and blunt, manual lysis of adhesions is performed in the suprapatellar pouch and the medial and lateral gutters with use of a sweeping motion after piercing and perforating the scarred adhesive bands or capsular tissue. Next, the arthroscope is inserted into the knee, and a diagnostic arthroscopy is performed. Bands of fibrous tissue are released and resected with use of electrocautery and a 4.0-mm arthroscopic shaver. Next, the posterior cruciate ligament (PCL) is visualized in full flexion. If PCL tightness is observed, the PCL can be released from its femoral origin until the flexion gap is increased. This portion of the procedure can include either partial or full release of the PCL, as indicated. Next, the arthroscope is removed and the ipsilateral hip is flexed to 90° for a standard MUA. Gentle force is applied to the proximal aspect of the tibia, and the knee is flexed. After completing the MUA, immediate post-intervention range of motion of the knee is documented, and the patient is provided with a continuous passive motion (CPM) machine set to the maximum flexion and extension achieved in the operating room. Nonoperative treatment of a stiff knee following total knee arthroplasty is well documented in the current literature. Range of motion has been shown to increase in patients undergoing proper pain management, aggressive physical therapy, and closed MUA in the acute postoperative setting. Additionally, more severe cases of established arthrofibrosis despite prior MUA can be treated with an open lysis of adhesions1-3. Arthroscopic lysis of adhesions with PCL release versus resection has been well described previously. This procedure has been shown to benefit patients in whom initial nonoperative treatment has failed. Additionally, this procedure is not limited to the immediate acute postoperative period like standard MUA3. To our knowledge, no technique video has been published outlining arthroscopic lysis of adhesions for a stiff knee following total knee arthroplasty. This procedure has been shown to provide an immediate and lasting improvement in the flexion and extension arc of the knee, as well as improved functional outcomes. Patients should be educated that improvements gained in the operating room must be sustained through physical therapy. In a study of 32 patients who underwent arthroscopic lysis of adhesions for moderately severe arthrofibrosis following a total knee arthroplasty, Jerosch and Aldawoudy reported a mean postoperative flexion of 119° in the operating room and 97° at the time of the latest follow-up. Eight patients with extensor lag showed improvement from 27° to 4°. Average Knee Society scores improved from 70 points preoperatively to 86 points at the time of the latest follow-up4. Their article showed that arthroscopic treatment of stiffness following total knee arthroplasty is a safe and effective form of treatment. Perform manual lysis of adhesions with a trocar prior to inserting the arthroscope in order to improve visualization and access.Utilize all portals and accessory portals interchangeably in order to improve access.Prescribe physical therapy with or without CPM machine immediately following surgery in order to maintain correction.Utilize pump inflow in order to help distend the tightened capsule.Protect the prosthetic surface from scratches during portal establishment.Loss of flexion implies scarring in the suprapatellar pouch and/or intercondylar notch, or PCL tightness.Loss of extension implies a tight posterior capsule, posterior osteophytes, or scarring of the PCL stump.A motorized shaver is the best tool for treatment of dense fibrous tissue, but be sure not to scratch metal total knee components. TKA = total knee arthroplastyROM = range of motionCT = computed tomographyMRI = magnetic resonance imagingESR = erythrocyte sedimentation rateCRP = C-reactive protein.