Initial Nonoperative Treatment Research Articles

Early palmar plate fixation of distal radius fractures may benefit patients aged 50 years or older: a randomized trial comparing 2 different treatment protocols

Background and purpose — There is no consensus regarding optimal treatment of displaced distal radius fractures (DRFs). We compared the results of 2 treatment protocols: early palmar plating vs. primary nonoperative treatment of displaced DRFs.Patients and methods — We performed a prospective randomized controlled study including 80 patients aged ≥ 50 years with dorsally displaced DRFs, excluding AO type C3 fractures. Patients were randomized to undergo either immediate surgery with palmar plating (n = 38), or initial nonoperative treatment (n = 42) after successful closed reduction in both groups. Delayed surgery was performed in nonoperatively treated patients showing early loss of alignment (n = 16). The primary outcome measure was Disabilities of the Arm, Shoulder, and Hand (DASH) score.Results — Mean DASH scores at 24 months in the early surgery group were 7.9 vs. 14 in the initial nonoperative group (difference between means 6, 95% CI 0.1–11, p = 0.05). Delayed operation was performed on 16/42 of patients due to secondary displacement in the initial nonoperative group. In “as treated” analysis, DASH scores were 7 in the early surgery group, 13 in the nonoperative group, and 17 after delayed surgery (p = 0.02). The difference in DASH scores between early and delayed surgery was 9 points (CI 0.3–19, p = 0.02)Interpretation — Treatment of DRFs with early palmar plating resulted in better 2-year functional outcomes for ≥50-year-old patients compared with a primary nonoperative treatment protocol. Delayed surgery in case of secondary displacement was not beneficial in terms of function.

Risk of Appendiceal Neoplasm in Periappendicular Abscess in Patients Treated With Interval Appendectomy vs Follow-up With Magnetic Resonance Imaging

The step after conservative treatment of periappendicular abscess arouses controversy, ranging from recommendations to abandon interval appendectomy based on low recurrence rates of the precipitating diagnosis to performing routine interval appendectomy owing to novel findings of increased neoplasm risk at interval appendectomy. To our knowledge, there are no randomized clinical trials with sufficient patient numbers comparing these treatments. To compare interval appendectomy and follow-up with magnetic resonance imaging after initial successful nonoperative treatment of periappendicular abscess. The Peri-Appendicitis Acuta randomized clinical trial was a multicenter, noninferiority trial conducted in 5 hospitals in Finland. All patients between age 18 and 60 years with periappendicular abscess diagnosed by computed tomography and successful initial nonoperative treatment from January 2013 to April 2016 were included. Data analysis occurred from April 2016 to September 2017. Patients were randomized either to interval appendectomy or follow-up with magnetic resonance imaging; all patients underwent colonoscopy. The primary end point was treatment success, defined as an absence of postoperative morbidity in the appendectomy group and appendicitis recurrence in the follow-up group. Secondary predefined end points included neoplasm incidence, inflammatory bowel disease, length of hospital stay, and days of sick leave. A total of 60 patients were included (36 men [60%]; median [interquartile range] age: interval appendectomy group, 49 [18-60] years; follow-up group, 47 [22-61] years). An interim analysis in April 2016 showed a high rate of neoplasm (10 of 60 [17%]), with all neoplasms in patients older than 40 years. The trial was prematurely terminated owing to ethical concerns. Two more neoplasms were diagnosed after study termination, resulting in an overall neoplasm incidence of 20% (12 of 60). On study termination, the overall morbidity rate of interval appendectomy was 10% (3 of 30), and 10 of the patients in the follow-up group (33%) had undergone appendectomy. The neoplasm rate after periappendicular abscess in this small study population was high, especially in patients older than 40 years. If this considerable rate of neoplasms after periappendicular abscess is validated by future studies, it would argue for routine interval appendectomy in this setting. ClinicalTrials.gov identifier: NCT03013686.

Results and Outcomes After Midshaft Clavicle Fracture: Matched Pair Analysis of Operative Versus Nonoperative Management.

This study evaluated patients with displaced clavicle fractures treated surgically vs nonoperatively. The authors hypothesized that functional outcomes would be no different. A retrospective comparative study was performed of 138 patients with closed midshaft clavicle fractures. Sixty-nine patients were treated operatively and matched for sex, age, and fracture pattern to 69 patients treated nonoperatively. Charts and radiographs were reviewed, and the American Shoulder and Elbow Surgeons survey was administered. A poor outcome was defined as a treatment complication or an American Shoulder and Elbow Surgeons score less than 60. There were 116 men and 22 women with a mean age of 37.7 years and fracture patterns of 15B-1 (n=78), 15B-2 (n=48), and 15B-3 (n=12). Thirty-seven percent were tobacco smokers, with 23 treated operatively and 28 nonoperatively. Ten (14.5%) initially nonoperative patients underwent plate fixation at a mean of 25.9 weeks (range, 7-48 weeks) because of persistent pain and motion at the fracture site. Fifteen (21.7%) of the 69 patients treated acutely with surgery had 16 complications, which resulted in secondary procedures in 11 patients (15.9%). Overall, poor outcomes occurred in 21 (30.4%) of 69 after fixation and in 19 (27.5%) of 69 in the nonoperative group. Unemployment (P=.05) and tobacco use (P=.03) were associated with poor outcome, irrespective of type of treatment. Initial nonoperative treatment presents a reasonable option for many patients. No differences in complications or poor outcomes were noted for surgical vs nonoperative treatment. Social factors proved to be greater predictors of outcome than other patient or injury features. Management of clavicle fractures should be individualized with assessment of patient expectations and activity level. Social factors should also be considered. [Orthopedics. 2018; 41(5):e689-e694.].

Outcomes in Thoracolumbar Burst Fractures With a Thoracolumbar Injury Classification Score (TLICS) of 4 Treated With Surgery Versus Initial Conservative Management.

This is a single-center, retrospective, observational cohort study. To determine whether surgery or nonoperative treatment has better clinical outcomes in neurologically intact patients with an intermediate severity thoracolumbar burst fracture. Optimal management, whether initial operative or nonoperative treatment, for thoracolumbar injury classification score (TLICS) 4 burst fractures remains controversial. Better insight into the treatment which affords patients a better clinical outcome could significantly affect patient care. This retrospective study included consecutive cases of TLICS 4 burst fracture patients from 2007 to 2013 and minimum 6-month follow-up. Potential confounders examined included age, sex, injury severity score, initial kyphotic angle, injured facets, and interspinous widening. Outcomes were determined by standardized questionnaires [Oswestry Disability Index (ODI), 12-item Short Form Physical Component Score (SF-12 PCS), and back pain Visual Analog Scale (VAS)] and analyzed using regression analysis. A total of 230 patients with burst fractures were identified, of which 67/230 (29%) were TLICS 4 and 47/67 (70%) had completed follow-up. No difference on univariate analysis was found between nonsurgical and surgical groups in mean ODI scores (P=0.27, t test), nor mean time to return to work (P=0.10, t test).Regarding outcomes, linear regression analysis revealed no association between having surgery and ODI (P=0.29), SF-12 PCS (P=0.59), or VAS (P=0.33). Furthermore, no difference was found between groups for employed patients working versus not working (P=0.09, the Fisher test), nor in mean time to return to work (P=0.30, Cox regression). This is one of the largest studies examining TLICS 4 burst fracture patients, adjusting for both clinical and radiologic confounders and reporting patient outcomes with minimum 6-month follow-up. No differences were found in outcomes between patients treated either surgically or nonsurgically. Studies focusing on early postoperative differences or cost-effectiveness might help in decision making. Level III.

Pelvic post-traumatic asymmetry: Assessment and sequenced treatment.

The most common cause of post-traumatic pelvic asymmetry is, by far, initial nonoperative treatment.Open reduction and internal fixation of unstable pelvic fractures are recommended to avoid pelvic nonunion or subsequent structural deformities.The most common symptom is pelvic pain. Pelvic instability is another symptom, as well as persistent urogenital problems and neurological sequelae.Preoperative evaluation of these patients requires careful clinical and functional assessment, in addition to a complete radiological study.Surgical treatment of pelvic fracture nonunions is technically demanding and has potentially serious complications.We have developed a new classification that modifies and completes Mears and Velyvis’s classification in which we highlight two types of post-traumatic sequelae with different clinical conditions and whose basic differentiating element is whether pelvic deformity is present or not. Based on this classification, we have established our strategy of surgical treatment.Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170069.

Nonoperative management of appendiceal phlegmon or abscess in children less than 3\xa0years of age

BackgroundIn children less than 3 years of age, there is little experience in the nonoperative management of appendiceal phlegmon or abscess (APA), especially in APA with an appendicolith. The purposes of this study were to evaluate the effects of an appendicolith and the success rate of nonoperative management for APA in these young children.MethodsChildren younger than 3 years of age with APA who underwent attempted initial nonoperative treatment between January 2008 and December 2016 were reviewed. Based on the presence or absence of an appendicolith on admission ultrasonography examination or computed tomography scan, children were divided into two groups: appendicolith group and no appendicolith group.ResultsThere were 50 children who met the study criteria. Among 50 children, three children failed to respond to nonoperative treatment because of aggravated intestinal obstruction or recurrent appendicitis within 30 days of admission. The overall success rate for nonoperative management of APA was 94% (47/50) in children younger than 3 years old. The rate of diarrhea and CRP levels were higher in the appendicolith group than that of the no appendicolith group (P < 0.05). However, the success rate and the hospital length of stay for nonoperative treatment in the appendicolith group and the no appendicolith group were similar without statistical significance.ConclusionAPA with or without an appendicolith can have nonoperative management without immediate appendectomy in children less than 3 years old.

Distal Radius Fractures: Does Obesity Affect Fracture Pattern, Treatment, and Functional Outcomes?

Distal radius fractures (DRFs) are 16% of fractures treated by orthopedic surgeons. Obesity's influence on DRF complexity has not been studied. This study was undertaken to determine if body mass index (BMI) affects DRF pattern, treatment, and functional outcomes. Part 1 was a retrospective review of patients who sustained a DRF after a fall from standing height with no prior reduction or treatment. Radiographs were classified as "simple" or "complex." Part 2 consisted of contacting patients from Part 1 and obtaining a Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. Retrospective review also identified patients who failed initial nonoperative treatment. Fracture pattern, failure of nonoperative treatment, and QuickDASH scores were compared with BMI at the time of injury. For Part 1, 130 patients (132 wrists) were identified. Average age was 57 years, 77% were female, and average BMI was 28.2 kg/m2. Each point increase in BMI increased the chance of having a complex DRF (odds ratio = 1.07). Part 2 identified 50 patients who completed a QuickDASH at an average of 4.6 years after injury. Those with a BMI <25 kg/m2 (n = 15) had an average QuickDASH score of 37; patients with a BMI ≥25 kg/m2 (n = 35) had an average QuickDASH score of 18. Increasing BMI was suggestive of a lower QuickDASH score ( P = .08). No significant difference was found with respect to BMI and failure of nonoperative treatment. A higher BMI increases the odds of a complex DRF. Despite more complex fractures, overweight patients may experience less disability after sustaining a DRF.

Delayed splenic rupture in massive splenomegaly - a case report

Introduction. We present a patient with a delayed rupture of the spleen following a mild abdominal trauma. For years, the patient was treated for hereditary massive splenomegaly with thrombocytopenia, without established etiology. Case Report. The initial non-operative treatment lasted seven days, after which the patient was readmitted to the Emergency Department with signs of intra-abdominal hemorrhage and underwent emergency open splenectomy. Even after pathohistological examination, the etiology of massive splenomegaly remained unknown. Conclusion. Conservative treatment is not recommended in cases of massive splenomegaly; thorough surgical observation in a tertiary care hospital with interventional radiology and a good multidisciplinary team is necessary, while splenectomy is a surgery of choice.

Patient profiling can identify patients with adult spinal deformity (ASD) at risk for conversion from nonoperative to surgical treatment: initial steps to reduce ineffective ASD management

Background ContextNon-operative management is a common initial treatment for patients with adult spinal deformity (ASD) despite reported superiority of surgery with regard to outcomes. Ineffective medical care is a large source of resource drain on the health system. Characterization of patients with ASD likely to elect for operative treatment from non-operative management may allow for more efficient patient counseling and cost savings. PurposeThis study aimed to identify deformity and disability characteristics of patients with ASD who ultimately convert to operative treatment compared with those who remain non-operative and those who initially choose surgery. Study Design/SettingA retrospective review was carried out. Patient SampleA total of 510 patients with ASD (189 non-operative, 321 operative) with minimum 2-year follow-up comprised the patient sample. Outcome MeasuresOswestry Disability Index (ODI), Short-Form 36 Health Assessment (SF-36), Scoliosis Research Society questionnaire (SRS-22r), and spinopelvic radiographic alignment were the outcome measures. MethodsDemographic, radiographic, and patient-reported outcome measures (PROMs) from a cohort of patients with ASD prospectively enrolled into a multicenter database were evaluated. Patients were divided into three treatment cohorts: Non-operative (NON=initial non-operative treatment and remained non-operative), Operative (OP=initial operative treatment), and Crossover (CROSS=initial non-operative treatment with subsequent conversion to operative treatment). NON and OP groups were propensity score-matched (PSM) to CROSS for baseline demographics (age, body mass index, Charlson Comorbidity Index). Time to crossover was divided into early (<1 year) and late (>1 year). Outcome measures were compared across and within treatment groups at four time points (baseline, 6 weeks, 1 year, and 2 years). ResultsFollowing PSM, 118 patients were included (NON=39, OP=38, CROSS=41). Crossover rate was 21.7% (41/189). Mean time to crossover was 394 days. All groups had similar baseline sagittal alignment, but CROSS had larger pelvic incidence and lumbar lordosis (PI-LL) mismatch than NON (11.9° vs. 3.1°, p=.032). CROSS and OP had similar baseline PROM scores; however, CROSS had worse baseline ODI, PCS, SRS-22r (p<.05). At time of crossover, CROSS had worse ODI (35.7 vs. 27.8) and SRS Satisfaction (2.6 vs. 3.3) compared with NON (p<.05). Alignment remained similar for CROSS from baseline to conversion; however, PROMs (ODI, PCS, SRS Activity/Pain/Total) worsened (p<.05). Early and late crossover evaluation demonstrated CROSS-early (n=25) had worsening ODI, SRS Activity/Pain at time of crossover (p<.05). From time of crossover to 2-year follow-up, CROSS-early had less SRS Appearance/Mental improvement compared with OP. Both CROSS-early/late had worse baseline, but greater improvements, in ODI, PCS, SRS Pain/Total compared with NON (p<.05). Baseline alignment and disability parameters increased crossover odds—Non with Schwab T/L/D curves and ODI≥40 (odds ratio [OR]: 3.05, p=.031), and Non with high PI-LL modifier grades (“+”/‘++’) and ODI≥40 (OR: 5.57, p=.007) were at increased crossover risk. ConclusionsHigh baseline and increasing disability over time drives conversion from non-operative to operative ASD care. CROSS patients had similar spinal deformity but worse PROMs than NON. CROSS achieved similar 2-year outcome scores as OP. Profiling at first visit for patients at risk of crossover may optimize physician counseling and cost savings.

Economic Decision Model for First-Time Traumatic Patellar Dislocations in Adolescents

Background: The surgical management of traumatic patellar dislocations in adolescents is associated with a lower rate of recurrent dislocations compared with nonoperative care. However, the attendant cost of surgery and the quality-of-life benefit of a surgical treatment strategy are unclear. Purpose: To compare the cost-utility of 3 management strategies for acute first-time patellar dislocations in adolescents: (1) nonoperative treatment only, (2) initial nonoperative treatment with surgery only for recurrent dislocations, and (3) immediate surgery. Study Design: Economic and decision analysis; Level of evidence, 2. Methods: A 10-year state-transition Markov model was constructed to compare the cost-utility of the 3 index treatment protocols. Utilities used to define health states were derived from a telephone interview of 60 adolescents with a history of acute patellar dislocations. The probability of transition between each health state was informed by the available literature. Direct costs were estimated using a statewide ambulatory surgery database, and indirect costs were estimated based on parental lost productivity. Effectiveness was expressed in quality-adjusted life years (QALYs). The principal outcome measure was the incremental cost-effectiveness ratio (ICER). Results: In the base case for our model, nonoperative treatment only was the least costly ($7300) but also the least effective (5.30 QALYs); initial nonoperative treatment with delayed surgery cost $10,500 for a 5.93 QALY benefit, while immediate surgical treatment cost $17,100 and provided 6.32 QALY benefits. Compared with nonoperative treatment only, initial nonoperative treatment with delayed surgery was associated with an ICER of $5100 per QALY. When immediate surgery was compared with a strategy of delayed surgery, immediate surgery provided incremental benefits at an ICER of $17,000 per QALY. The model was sensitive to the probability of surgical versus nonoperative treatment to achieve a full return to preinjury activity versus an intermediate lower state. When the probability of achieving a full return to preinjury activity with initial nonoperative treatment exceeds 47.5% (compared with 34.2% in the base case), then initial nonoperative treatment with delayed surgery is preferred to immediate surgery. Similarly, when the probability of achieving a full return to full preinjury activity with surgery falls below 51% (compared with 64% in the base case), then delayed surgery after initial nonoperative treatment is preferred. Conclusion: Immediate surgery and delayed surgical treatment are both cost-effective treatment options; however, immediate surgical treatment provides the highest QALY gains within a 10-year time horizon. Our model sensitivity analysis highlights the role of optimizing functional and quality-of-life benefits in the treatment of acute traumatic patellar dislocations. These findings have implications for clinical guidelines and policy decisions relating to adolescent patellar dislocations.

Magnetic Resonance Imaging Predictors of Failure in the Nonoperative Management of Ulnar Collateral Ligament Injuries in Professional Baseball Pitchers

Background: A medial ulnar collateral ligament (UCL) injury of the elbow is an increasingly common injury in professional baseball pitchers. Predictors of success and failure are not well defined for the nonoperative management of these injuries. Purpose: To evaluate the efficacy of objective measures to predict failure of the nonoperative management of UCL injuries. Study Design: Case-control study; Level of evidence, 3. Methods: Thirty-two professional pitchers (82%) met inclusion criteria and underwent an initial trial of nonoperative treatment for UCL tears based on clinical and radiological findings. Age, preseason physical examination results, magnetic resonance imaging (MRI) characteristics, and performance metrics were analyzed for these pitchers. Successful nonoperative management was defined as a return to the same level of play or higher for >1 year. Failure was defined as recurrent pain or weakness requiring a surgical intervention after a minimum of 3 months’ rest when attempting a return to a throwing rehabilitation program. Results: Thirty-two pitchers (mean age, 22.3 years) who underwent initial nonoperative treatment of UCL injuries were evaluated. Thirty-four percent (11/32) failed and required subsequent ligament reconstruction. Sixty-six percent (21/32) successfully returned to the same level of play for 1 year without a surgical intervention. There was no significant difference seen in physical examination findings or performance metrics between these patients. When comparing MRI findings between the groups, 82% (9/11) (P < .001) who failed nonoperative management had distal tears, and 81% (17/21) who did not fail had proximal tears (P < .001). When adjusting for age, location, and evidence of chronic changes on MRI, the likelihood of failing nonoperative management was 12.40 times greater (P = .020) with a distal tear. No other variable alone or in combination reached significance. When combining the parameters of a high-grade tear and distal location, 88% (7/8) failed nonoperative management. Conclusion: In professional pitchers, distal UCL tears showed significantly higher odds of failure with nonoperative management compared with proximal tears. Thus, tear location should be considered when deciding between operative and nonoperative management.

Rehabilitation of Achilles tendon ruptures: is early functional rehabilitation daily routine?

Ruptures of the Achilles tendon are the most common tendon injuries of the lower extremities. Besides the initial operative or non-operative treatment, rehabilitation of patients plays a crucial role for tendon healing and long-term outcome. As only limited evidence is available for optimized rehabilitation regimen and guidelines for the initial (e.g., first 6weeks) rehabilitation are limited, this study investigated the current rehabilitation concepts after Achilles tendon rupture. We analyzed 213 written rehabilitation protocols that are provided by orthopedic and trauma surgery institutions throughout Germany in terms of recommendations for weight-bearing, range of motion (ROM), physiotherapy, and choice of orthosis. All protocols for operatively and non-operatively treated Achilles tendon ruptures were included. Descriptive analysis was carried out and statistical analysis applied where appropriate. Of 213 institutions, 204 offered rehabilitation protocols for Achilles tendon rupture and, therefore, 243 protocols for operative and non-operative treatment could be analyzed. While the majority of protocols allowed increased weight-bearing over time, significant differences were found for durations of fixed plantar flexion between operative (o) and non-operative (n) treatments [fixed 30° (or 20)° to 15° (or 10)°: 3.6weeks (±0.1; o) vs 4.7weeks (±0.3; n) (p ≤ 0.0001) and fixed 15° (or 10)° to 0°: 5.8weeks (±0.1; o) vs 6.6weeks (±0.2; n) (p ≤ 0.001)]. The mean time of the recommended start of physiotherapy is at 2.9 weeks (±0.2; o) vs 3.3 weeks (±0.4; n), respectively. Our study shows that a huge variability in rehabilitation after Achilles tendon rupture exists. This study shows different strategies in rehabilitation of Achilles tendon ruptures using a convertible vacuum brace system. To improve patient care, further clinical as well as biomechanical studies need to be conducted. This study might serve as basis for prospective randomized controlled trials to optimize rehabilitation for Achilles tendon ruptures.

A Prospective Assessment of Clinical and Patient-Reported Outcomes of Initial Non-Operative Management of Ventral Hernias.

Little is known about the clinical or patient-reported outcomes with non-operative management of ventral hernias. The aim of this prospective study is to determine the clinical and patient-reported outcomes of patients undergoing initial non-operative treatment of their ventral hernia. This was a prospective observational study of patients undergoing non-operative management of ventral hernias. Primary outcome was rate of surgical repair of the ventral hernias. Secondary outcomes included rate of emergency repair, elective repair, and emergency room visits. In addition, validated measurement tools for patient satisfaction and cosmetic satisfaction with their abdomen, abdominal pain, and patient function (modified Activities Assessment Scale, AAS) were utilized. Of 128 patients who underwent non-operative management of a ventral hernia, 99(77.3%) patients were followed for a median (interquartile range) of 12.2(10.4-13.5) months. Twenty (20.2%) patients had at least 1 emergency room visit associated with their hernia. One-quarter (n=2323.2%) underwent ventral hernia repair following enrollment. Twenty (20.2%) underwent elective repair, and 3 (3.0%) underwent emergent repair. Based on the modified AAS survey, patients who were managed non-operatively experienced no change in patient centered outcomes, while patients converted to operative management had improved scores. While the short-term risk of emergency surgery with non-operative management of ventral hernias is moderate, the chance of an emergency room visit and surgery is high. Patients who undergo non-operative management of their ventral hernias have no change in patient-reported outcomes at one year, while those converted to operative management experience improvement.

Comparing fracture healing disorders and long-term functional outcome of polytrauma patients and patients with an isolated displaced midshaft clavicle fracture

Although clavicle fractures are a common injury in polytrauma patients, the functional outcome of displaced midshaft clavicle fractures (DMCFs) in this population is unknown. Our hypothesis was that there would be no differences in fracture healing disorders or functional outcome in polytrauma patients with a DMCF compared with patients with an isolated DMCF, regardless of the treatment modality. A retrospective cohort study of patients (treated at our level I trauma center) with a DMCF was performed and a follow-up questionnaire was administered. Polytrauma patients, defined as an Injury Severity Score ≥16, and those with an isolated clavicle fracture were compared. Fracture healing disorders (nonunion and delayed union) and delayed fixation rates were determined. Functional outcome was assessed by the Quick Disability of the Arm, Shoulder, and Hand questionnaire. A total of 152 patients were analyzed, 71 polytrauma patients and 81 patients with an isolated DMCF. Questionnaire response of 121 patients (80%) was available (mean, 53 months; standard deviation, 22 months). No differences were found between polytrauma patients and those with an isolated DMCF with regard to nonunion (7% vs. 5%, respectively), delayed union (4% vs. 4%), and delayed fixation rate (13% vs. 13%). Polytrauma patients had an overall worse functional outcome, regardless of initial nonoperative treatment or delayed operative fixation. Polytrauma patients had a similar nonunion and delayed fixation rate but had an overall worse functional outcome compared with patients with an isolated DMCF. For polytrauma patients, a wait and see approach can be advocated without the risk of decreased upper extremity function after delayed fixation.

Arthroscopic Plafond Access for Osteochondral Lesions- The Effect of Limited Ankle Range of Motion on Anterior and Posterior Arthroscopic Accessibility

Category: Arthroscopy. Introduction/Purpose: Osteochondral lesions of the tibial plafond (OLTPs) can lead to chronic ankle pain and disability. Arthroscopic treatment has been described after failure of initial nonoperative treatment. However, the ideal appropriate approach for OLTPs is controversial, and it is not known if ankle positioning or joint distraction affects the accessibility of these lesions. The purpose of this study was to determine the effects of predetermined ankle flexion angles on arthroscopic accessibility of the distal tibial articular surface through either the anterior or posterior approach. The effects of non- invasive joint distraction were also analyzed. Methods: Fourteen below-knee cadaver specimens were subjected to pre-operative range of motion measurements. Joint distraction was measured using sizing rods with the precision of 1 mm. The accessible areas at the tibial plafond were marked using a curette at predetermined ankle positions. Arthroscopy was performed using a 30-degree 2.7 mm camera via standard anterior and posterior approaches in randomized fashion in all specimens. Following arthroscopic accessibility, each cadaveric ankle was disarticulated and arthroscopic accessibility was quantified using a surface laser scan. Statistical analyses were performed to determine the correlation between pre-operative ankle range of motion and amount of distraction on arthroscopic accessibility of the tibial plafond. Results: The average accessibility of the tibial plafond was 56 percent and 68 percent for the anterior and posterior approaches, respectively (p = 0.056). There was no difference in accessibility from the anterior approach with increasing level of plantarflexion (p &gt;0.05). Increasing dorsiflexion during the posterior approach significantly reduced ankle accessibility (p = 0.028). There was a significant increase in accessibility through either anterior or posterior approach with increasing level of ankle distraction; (parameter estimates ±SE): anterior= 14.2±3.34, p &lt; 0.01 and posterior= 10.6±3.7, p &lt; 0.05). Conclusion: Arthroscopic accessibility for the treatment of OLTPs was vastly dependent on the amount of intra-operative joint distraction achieved. Posterior approach had more joint distraction and wider plafond accessibility. Increasing ankle distraction significantly improved arthroscopic plafond accessibility for both anterior and posterior approaches while ankle joint position did not influence accessibility from either approach.

Diverticular Abscess Managed With Long-term Definitive Nonoperative Intent Is Safe.

Initial nonoperative management of diverticular abscess has become the standard of care; however, the need for elective resection after this index episode is unclear. The purpose of this study was to assess the long-term outcomes of expectant management after initial nonoperative treatment of diverticular abscess. This was a retrospective chart review with prospective telephone follow-up of patients. The study was conducted at a large tertiary academic colorectal surgery practice in Canada. Adult patients with CT-documented acute sigmoid diverticulitis complicated by abscess managed nonoperatively from 2000 to 2013 were included. Long-term definitive nonoperative management of diverticular abscess. The primary outcome was emergency sigmoidectomy or death from recurrent diverticulitis. Secondary outcomes were recurrent diverticulitis and elective sigmoidectomy for diverticulitis. Of 135 patients with acute diverticulitis complicated by abscess, a total of 73 patients were managed with nonoperative intent and long-term expectant management. The median follow-up was 62 (Q1 to Q3: 28-98) months. After resolution of the index episode, 22 patients [30.1% (95% CI, 19.6%-40.6%)] experienced a recurrent episode of diverticulitis at a median of 23 (range, 9-40) months. Two patients [2.7% (95% CI, -1.0% to 6.4%)] had a recurrent episode with peritonitis that required sigmoidectomy with stoma at 6 and 64 months. Both patients underwent reversal after 4 and 8 months. Seven [9.6% (95% CI, 2.8%-16.4%)] patients experienced a complicated recurrence and underwent an elective sigmoidectomy [median time to colectomy, 33 (range, 16-56) months]. Thirteen patients [17.8% (95% CI, 9.0%-26.6%)] experienced an uncomplicated recurrence, all of whom were managed with continued nonoperative intent [median follow-up, 81 (range, 34-115) months]. No mortality occurred. On multivariate logistic regression, female gender (p = 0.048) and a previous episode of uncomplicated diverticulitis before the index diverticular abscess (p = 0.020) were associated with a recurrent episode. This study was limited by its retrospective design and modest sample size. After initial successful nonoperative management of diverticulitis with abscess, expectant management with nonoperative intent is a safe long-term option with low rates of surgery, especially in the emergency setting. See Video, Supplemental Digital Content 1, on the nonoperative management of diverticular abscess at http://links.lww.com/DCR/A234.

Clinical Relevance Commentary in Response to: Coaching of patients with and isolated minimally displaced fracture of the radial head immediately increases range of motion

Even a minor injury occurring at the elbow can result in limitations in elbow active range of motion (AROM). 18 Sardelli M. Tashjian R.S. MacWilliams B.A. Functional elbow range of motion for contemporary task. J Bone Joint Surg Am. 2011; 93: 471-477 Crossref PubMed Scopus (150) Google Scholar , 21 Morrey B.F. An K.N. Functional evaluation of the elbow. in: Morrey B.F. The Elbow and Its Disorders. 3rd ed. WB Saunders, Philadelphia, PA2000: 74-83 Google Scholar It is widely accepted that patient participation in a home program has been an integral component of therapy to facilitate improvements in motion, function, and reduction of pain. My clinical experience is consistent with the finding that patients with Broberg-Morrey–modified Mason type 1 or 2 fracture 1 Broberg M.A. Morrey B.F. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res. 1987; 216: 109-119 PubMed Google Scholar of the radial head or the neck often may have reports of pain, stiffness, swelling, limited AROM, and limitations in function immediately after the period of initial nonoperative treatment of rest. I concur that patients typically show some improvement in AROM on the same day when the protection of a sling/splint is discontinued, are instructed in safe parameters of exercise, and have the opportunity to demonstrate correct exercise and activity performance.

Management of the Biceps Tendon

The long head of the biceps tendon (LHBT) is a common source of pathology in overhead athletes. The biceps-labrum complex is the combined anatomy of the LHBT and superior labrum, and it is imperative to understand this complex anatomical relationship for both diagnosis and management of these conditions. The etiology of LHBT pathology can be classified into the following 3 categories: inflammation, instability, and trauma. Although there are many physical examination tests for biceps tendon and superior labrum anterior to posterior lesions, many of these lack reproducible sensitivity or specificity to be clinically useful. Owing to the difficulty in diagnosing LHBT disorders, treatment should be guided by a combination of history and clinical examination findings as well as advanced imaging studies, including magnetic resonance imaging and ultrasound. Initial nonoperative treatment of LHBT pathology includes guided physical therapy, nonsteroidal anti-inflammatory medications, and corticosteroid injections. When nonoperative management fails, surgical treatment includes the following 3 common procedures: superior labrum anterior to posterior repair, biceps tenotomy, and biceps tenodesis. When treated appropriately, overhead athletes with LHBT pathology often experience excellent clinical outcomes.

Trends in the Diagnosis and Management of Pediatric Appendicitis

• On the basis of class B evidence and consensus, acute appendicitis in children can often be diagnosed clinically with only selective use of imaging. (13)(14)(15)(16) • On the basis of class B evidence and consensus, ultrasonography is the test of choice when acute appendicitis is suspected but is unclear based on history, physical examination, and laboratory results. (17)(18)(19) • On the basis of class B evidence and consensus, the use of computed tomography scan should be limited to cases of suspected complex appendicitis with abscess or when there is clinical suspicion for acute appendicitis but ultrasonography results are not helpful. (16) • On the basis of class C evidence and consensus, children with possible appendicitis ideally should be treated in medical centers that have skilled sonographic personnel. (21) • On the basis of class B evidence and consensus, simple appendicitis should be treated by appendectomy during normal operating hours. Preoperative treatment with intravenous antibiotics and fluids during the overnight hours halts disease progression and allows for the safest surgery with the benefit of a full and rested staff. (24)(25)(26) • On the basis of class B evidence and consensus, complex appendicitis with a well-defined abscess can be treated nonoperatively initially, with the option of an interval appendectomy after recovery from the acute infection. (29)(30) (31)(32)(33)

Analysis of 213 currently used rehabilitation protocols in foot and ankle fractures

IntroductionFractures of the ankle, hind- and midfoot are amongst the five most common fractures. Besides initial operative or non-operative treatment, rehabilitation of the patients plays a crucial role for fracture union and long term functional outcome. Limited evidence is available with regard to what a rehabilitation regimen should include and what guidelines should be in place for the initial clinical course of these patients. This study therefore investigated the current rehabilitation concepts after fractures of the ankle, hind- and midfoot. MethodsWritten rehabilitation protocols provided by orthopedic and trauma surgery institutions in terms of recommendations for weight bearing, range of motion (ROM), physiotherapy and choice of orthosis were screened and analysed. All protocols for lateral ankle fractures type AO 44A1, AO 44B1 and AO 44C1, for calcaneal fractures and fractures of the metatarsal as well as other not specific were included. Descriptive analysis was carried out and statistical analysis applied where appropriate. Results209 rehabilitation protocols for ankle fractures type AO 44B1 and AO 44C1, 98 for AO 44A1, 193 for metatarsal fractures, 142 for calcaneal fractures, 107 for 5th metatarsal base fractures and 70 for 5th metatarsal Jones fractures were evaluated. The mean time recommended for orthosis treatment was 6.04 (SD 0.04) weeks. While the majority of protocols showed a trend towards increased weight bearing and increased ROM over time, the best consensus was noted for weight bearing recommendations. ConclusionOur study shows that there exists a huge variability in rehabilitation of fractures of the ankle-, hind- and midfoot. This may be contributed to a lack of consensus (e.g. missing publication of guidelines), individualized patient care (e.g. in fragility fractures) or lack of specialization. This study might serve as basis for prospective randomized controlled trials in order to optimize rehabilitation for these common fractures.