Months Of Conservative Treatment Research Articles

Percutaneous Transforaminal Endoscopic Diskectomy for Lumbar Disk Herniation: Young (Age

We compare the differences in the efficacy of percutaneous transforaminal endoscopic diskectomy (PTED) between the younger (age <60 years) and older (age ≥60 years) patients with lumbar disk herniation (LDH). From December 2016 to December 2017, 128 patients with symptomatic LDH underwent PTED and were followed up. Forty-four 60 years old and above, including 19 males and 25 females with an average age of 68.7 (61-82) years, were classified as the elderly age group. Eighty-four patients younger than 60 years were classified as the young age group, which included 48 males and 36 females with an average age of 44.7 (16-58) years. The visual analog scale (VAS) scores, Japanese Orthopaedic Association (JOA) scores, and satisfaction rates of the two groups before and after surgery were compared. The operation was completed successfully in both groups. The average follow-up times of the elderly and young age groups were 18.47 ± 2.62 (12-23) and 17.90 ± 3.27 (12-23) months, respectively. One patient in the young age group had recurrence 7 months after surgery, and the symptoms were relieved after PTED was performed again. Two patients with nerve root injury after surgery in the young age group completely recovered after 2 months of conservative treatment. There were no significant surgical complications in the elderly age group. There was no significant difference in postoperative VAS, JOA, and MacNab scores between the two groups. The MacNab scores in the elderly age group were excellent for 28 patients, good for 10 patients, and fair for 6 patients; the satisfaction rate was 86.3%. In the young age group, scores were excellent for 63 patients, good for 14 patients, fair for 5 patients, and poor for 2 patients; the satisfaction rate was 91.7%. The clinical effectiveness of PTED for treatment of LDH in both elderly and young patients is satisfactory. Age is not a predictor of poor outcomes of PTED.

CONSERVATIVE MANAGEMENT OF ACUTE LUMBAR DISC HERNIATION WITH ASSOCIATED RADICULOPATHY: A STUDY

Objective: Acute disc herniation (DH) is a common cause of low back pain (LBP). It ranks fifth in the category of diseases in terms of cost of hospital care. It has higher indirect costs due to absenteeism from work and disability than any other disease. The present study was performed to assess the clinical outcomes of non-surgically treated LBP patients after 6 months of follow-up. Methods: The present study was prospective study which was performed on 450 lumbar radicular patients visiting the neurosurgery outpatient department having clinical signs and symptoms of acute lumbar DH of less than 3 month duration. Their diagnosis was confirmed by magnetic resonance imaging. The patients were treated conservatively during 6 months. Pain and disability were assessed by visual analog scale (VAS) and Oswestry disability questionnaire, respectively. Results: About 135 (30%) female and 315 (70%) male participated in the study. During the follow-up period, 27 (06%) patients (21 male and 6 female) showed poor response to conservative treatment and motor weakness and underwent surgical intervention. A significant improvement in the VAS Score was seen after 6 months of conservative treatment than initial evaluation of patients (3.12±1.84, 7.1±1.43, p=0.00). Furthermore, significant improvement in disability score of patients was seen in follow-up period (25.82±16.92, 53.66±17.66; p=0.00). Conclusion: Results of our study showed that conservative treatment in patients of acute lumbar DH have significant improvement in pain relief and disability without any notable side effect.

Total Hip Replacement for Osteoarthritis-Evidence-Based and Patient-Oriented Indications.

Total Hip Replacement (THR) belongs to the most common inpatient operations in Germany, with over 240 000 procedures performed per year. 90% of the artificial joints are still functional at 15 years, and up to 60% at 20 years after surgery. It is essential that the indications for such procedures should be uniform, appropriate, and patient-oriented. This review is based on publications retrieved by a systematic literature search for national and international guidelines and systematic reviews on the topic of hip osteoarthritis and THR. THR should be performed solely with radiologically demonstrated advanced osteoarthritis of the hip (Kellgren and Lawrence grade 3 or 4), after at least three months of conservative treatment, and in the presence of high subjective distress due to symptoms arising from the affected hip joint. Contraindications include refractory infection, acute or chronic accompanying illnesses, and BMI ≥= 40 kg/m2. Patients should stop smoking at least one month before surgery. In patients with diabetes mellitus, preoperative glycemic control to an HbA1c value below 8% is advisable. It is recommended that patients should lower their weight below a BMI of 30 kg/m2. The decision to perform THR should be taken together by both the physician and the patient when the expected treatment benefit outweighs the risks. Evidence suggests that a worse preoperative condition is associated with a poorer surgical outcome.

Transcatheter Arterial Embolization Using Imipenem/Cilastatin Sodium for Chronic Low Back Pain Resistant to Conservative Treatment: A Pilot Study with 2-Year Follow-Up.

To evaluate the safety and 2-year follow-up clinical outcomes of transcatheter arterial embolization (TAE) using imipenem/cilastatin sodium for chronic low back pain resistant to conservative treatment. A retrospective review identified 14 patients who underwent TAE for chronic low back pain between October 2017 and August 2018. Patients with low back pain related to the facet or sacroiliac joint, lasting ≥ 6months, refractory to ≥ 3months of conservative treatment were eligible for TAE. Each patient received embolization of feeding arteries of painful regions. The changes in brief pain inventory (BPI) scores, adverse events, and the Oswestry Disability Index (ODI) were evaluated at baseline and 1, 3, and 24months after TAE. Clinical success was defined as BPI maximum pain intensity decrease of ≥ 2 and ODI decrease of ≥ 10 points from baseline. Follow-up data were available in 13 and 11 patients, at 3 and 24months after embolization, respectively. Intention-to-treat clinical success was obtained in 11/14 (79%) of patients at 3months and 8/14 (57%) of patients at 24months after TAE. Mean BPI maximum pain intensity and ODI scores decreased significantly from baseline to 1, 3, and 24months after treatment (7.6 vs.. 4.3, 3.4, and 4.1; 40.8 vs 21.5, 20.0, and 23.8, respectively; all P < 0.01). No major adverse events were associated with the procedures. TAE is one possible treatment option for patients with chronic low back pain refractory to conservative treatment.

Intradiscal Injection with Condoliase (Chondroitin Sulfate ABC Endolyase) for Painful Radiculopathy Caused by Lumbar Disc Herniation.

Introduction Chemonucleolysis with condoliase (chondroitin sulfate ABC endolyase) has been used to treat patients with lumbar disc herniation (LDH) in Japan since 2018. In this study, we retrospectively investigated clinical outcomes in patients who received an intradiscal condoliase injection for LDH and sought to identify significant predictors of good outcome. Methods Indications for treatment were as follows: (1) unilateral leg pain with or without back pain, (2) nerve root compression caused by LDH confirmed on magnetic resonance imaging (MRI), and (3) leg pain resistant to at least 1 month of conservative treatment, including medication, nerve root block, or physical therapy. Patients with motor weakness or a history of severe allergy were excluded, as were those with the foraminal or sequestrated type of LDH. The injection was defined as effective if the numeric rating scale score for leg pain improved by ≥50% at 6 months post-treatment. Results A total of 52 patients (mean age, 45.0 years) were enrolled and classified according to whether the injection was effective (E group, n=40, 76.9%) or less effective (L group, n=9, 17.3%). Three patients (5.8%) underwent herniotomy for residual pain within 6 months of the injection. There were no severe adverse events. Reduction of herniation was seen on MRI more often in the E group than in the L group. The effectiveness in patients with transligamentous LDH was similar to that in patients with subligamentous LDH. High-intensity signal change in the area of LDH on pretreatment T2-weighted MRI was a significant predictor of successful leg pain relief. Conclusions An intradiscal condoliase injection was a safe and effective treatment for painful radiculopathy caused by LDH. Leg pain was more likely to improve in patients with high-intensity signal change in the area of LDH before treatment.

223. The psychological burden of disease among patients undergoing cervical spine surgery: are we underestimating our patients’ inherent disability?

<h3>BACKGROUND CONTEXT</h3> Recent studies have suggested that for patients with chronic neck pain, both psychological and psychosomatic symptoms need to be addressed as psychological distress is associated with poor outcomes in these patients. The fear avoidance model has been used to explain how maladaptive thoughts and behaviors contribute to chronicity and disability. Certain mental health scores have been previously analyzed in patients with pathologies in different spinal regions. However, these rates have yet to be assessed against patients undergoing cervical spine surgery. <h3>PURPOSE</h3> Identify the psychological burden among patients undergoing surgical treatment for their symptomatic cervical degenerative disease. <h3>STUDY DESIGN/SETTING</h3> Single-center prospective double-blinded, randomized control trial that consists of patients undergoing surgical arthrodesis for 3 single- or multilevel cervical disease, resulting in cervical radiculopathy. <h3>PATIENT SAMPLE</h3> This study included 47 symptomatic cervical degenerative disorders patients. <h3>OUTCOME MEASURES</h3> Fear Avoidance Beliefs Questionnaire (FABQ), Pain Catastrophizing Scale (PCS). Neck Disability Index (NDI), EuroQol Five Dimensions (EQ5D). <h3>METHODS</h3> A total of 47 patients age >18 with symptomatic cervical degenerative disease were included and those with active depression or history of major depression were excluded from the study. Basic demographics and baseline HRQLs (NDI, EQ5D, PCS, FABQ) were assessed via descriptive analyses. Patient psychosomatic scores that measure preoperative pain catastrophe and fear avoidance of procedure (PCS, FABQ) were compared to previously published benchmarks in a lumbar spine population. These mental health components and disability were further stratified by their severity as previously published (PCS >30; FABQ >34). Correlations assessed the relationship between these mental health components and severity of disability described by NDI (Not Disabled=0-4, Mild=5-14, Moderate=15-24, Severe=25-34, Complete=34+). Furthermore, logistic regressions were analyzed to determine whether NDI was an independent predictor of psychological burden described by PCS and FABQ. <h3>RESULTS</h3> Forty-seven patients were enrolled (age 53.6 years, BMI 29.4 kg/m2). 32% of these patients were diagnosed with radiculopathy, 26% with myelopathy, and 42% with concomitant imaging diagnosis (hnp, ddd, spondylosis all with or without central stenosis). These patients were all scheduled to undergo spinal fusions with decompression and had failed at least 3 months of conservative treatment. The average number of levels fused was 2.27±1.4. At baseline, the average PCS was 27.4 and FABQ: 40. By overall health metrics, the patient population had an average EQ5D score of 9.3 and an NDI of 25.6. 57.1% of patients had a severe FABQ, 40.8% had a severe PCS, and 27.7% had a severe NDI score. As compared to historical controls of lumbar patients, the patients in this study had greater levels of psychosomatic pathology measured by FABQ (40 vs 17.55; p<0.001) and PCS (27.4 vs 19.25; p<0.001). PCS was positively correlated with FABQ scores (r=0.55; p<0.001). Increasing neck disability was correlated with greater PCS measured disability (Overall r=0.7, Complete r=0.58; p<0.05). Being completely disabled was also identified to have a significant relationship with having a severe PCS score independent of levels fused and diagnosis (OR=11.7[1.5-90.5]; p=0.019). This trend was similarly identified for FABQ (Overall r=0.5, Complete r=0.4; all p<0.05). Age was also not a significant predictor for baseline severe PCS and FABQ nor were diagnosis and presence of stenosis. <h3>CONCLUSIONS</h3> Cervical spine patients have an overall great amount of mental health pathology; however, a large portion of these patients also have high fear avoidance beliefs and pain catastrophizing at baseline. These rates were identified to be higher than previously identified benchmarks of lumbar spine patients. Because this study excluded patients with an official diagnosis of depression or other psychological condition, it is reasonable to say that the mental health pathology of patients undergoing cervical surgery is greatly underestimated and should warrant preoperative treatment to help mitigate these mental health scores at baseline. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Advanced Physical Rehabilitation in Hairline Coccyx Fracture: A Case Report

Background: The fracturing of Coccyx is an injury normally caused by trauma. A fall on the buttocks can cause a coccyx fracture that may go radiographically unnoticed. There is substantial discomfort in the patient that can persist for months. Coccygectomy is suggested in cases that, after more than 2 months of conservative treatment, demonstrate coccydynia. There is little evidence available on the feasibility of this technique, though, and it is considered to have a high complication rate. As such, it requires other treatment techniques.Here, in order to effectively minimize coccydynia in a coccyx fracture patient, we report our experience using another conservative treatment option. The care consists largely of resting, physiotherapy and analgesics.&#x0D; Presenting Symptoms and Diagnosis: : A 21-year-old girl had increased pain i.e. coccydynia after a traffic accident( RTA) induced by coccyx fracture. She visited physiotherapy department with complaints of pain in coccyx area, tenderness, difficulty in mobility (pain while standing from sitting position) and difficulty in performing activities of daily living (ADL). Patient gives history of road traffic accident 2 months ago, a autorickshaw dashed the patient from behind. She went to orthopedic department where X-ray was performed and she diagnosed with hairline coccyx fracture. On inspection, patient was in pain, her NPRS score was 8. Her pain was aggravated by movements and relieved at rest. Patient came with slight stooping posture. On palpation we did found that the swelling and tenderness was present with tightness. Whereas on musculoskeletal assessment, we found that there was decreased range of motion, hypomobile joints, increased tone and muscle spasm.&#x0D; Therapeutic Intervention and Outcomes: Patient was on medical treatment and bed-rest, treated with the analgesic and use of ring cushion was advised. She was also advised to reduce the weight bearing on buttocks. Cross-strapping of buttocks was done. After the completion of bed-rest, her condition was improved but she was having pain and could not perform squatting activities and other activities of daily living. Physiotherapy treatment was planned for the same.&#x0D; Conclusion: Timely physiotherapy treatment is quite helpful to perform her everyday activities independently. This case study reveals the patient with hairline coccyx fracture experience full recovery after conservation management.

Extracapsular subcutaneous endoscopic treatment for refractory lateral epicondylalgia: technique, retrospective results, and prognostic factors.

BackgroundThe extracapsular subcutaneous endoscopic treatment is a new and under-researched approach to the endoscopic treatment of refractory lateral epicondylalgia. We aimed to introduce the techniques of the method and the mid-long term clinical effects. Furthermore, we intended to identify demographic and surgical-related factors correlated with prognosis of extracapsular subcutaneous method.MethodsPatients with a minimum of 6 months of conservative treatment for lateral epicondylalgia were recruited from March 2012 to July 2018. Key surgical techniques including microfracture and endoscopic suture were used. Visual analog scale (VAS), Mayo Elbow Performance Score (MEPS), and Disability of Arm (Shoulder and Hand, DASH) scores were used to evaluate clinical results. Univariable analysis and multivariable logistic regression were used to analyze effects of demographic characteristics and treatment techniques on prognosis.ResultsSeventy-eight patients were treated with modified subcutaneous extracapsular surgery. No serious complications such as neurovascular injury or infection occurred. Postoperative VAS, MEPS, and DASH scores significantly improved (P<0.001). Age was associated with prognosis regarding VAS score (P=0.023). Older age was an independent relevant factor for poor prognosis regarding VAS score (OR =0.914, 95% CI: 0.842–0.993, P=0.033), and microfracture during surgery related to poor prognosis for DASH score (OR =0.056, 95% CI: 0.004–0.783, P=0.032). Plaster fixation was an independent factor related to good prognosis regarding DASH score (OR =11.156, 95% CI: 1.009–123.363, P=0.049).ConclusionsExtracapsular subcutaneous method of refractory lateral epicondylalgia has satisfactory and stable clinical results with high safety. Techniques of extracapsular method include debridement, microfracture, and tendon suture under endoscope. Young age, no microfracture, and postoperative plaster fixation were associated with good long-term prognosis.

Endoscopic Tenotomy for Iliopsoas Tendinopathy Following Total Hip Arthroplasty Can Relieve Pain Regardless of Acetabular Cup Overhang or Anteversion

To report outcomes of endoscopic iliopsoas tenotomy (EIT) in patients with iliopsoas tendinopathy following total hip arthroplasty (THA) and determine whether improvements in clinical scores are associated with acetabular cup anteversion measured on plain radiographs or overhang measured using established and alternative computed tomography (CT)-based methods. We evaluated patients who underwent EIT for iliopsoas tendinopathy after THA (2014-2017), performed between the lesser trochanter and psoas valley. Indications were groin pain during active hip flexion, exclusion of other complications, and no pain relief after 6 months of conservative treatment. Pretenotomy inclination and anteversion were measured on radiographs; sagittal and axial overhang were measured on CT scans on slices passing through: (Method 1) prosthetic head center and (Method 2) anterior margin of acetabular cup. Modified Harris hip score (mHHS), Oxford Hip Score (OHS), and level of groin pain were recorded at 12 or more months. Wilcoxon signed-rank tests were used to compare pre- and post-tenotomy scores, and intraclass correlation coefficients (ICCs) to assess intermethod agreement. The cohort comprised 16 men (17 hips) and 32 women (33 hips), aged 60.8 ± 10.5 years at EIT. For the 30 (60%) hips that had pretenotomy CT scans, axial and sagittal overhang were, respectively, 3.4 ± 3.7 mm and 4.6 ± 4.6 mm, using Method 1, compared with 3.9 ± 3.9 mm and 6.9 ± 5.0 mm using Method 2. Intermethod agreement was good for axial (ICC, 0.67; P < .001) and sagittal (ICC, 0.68; P < .001) overhang. At a minimum 1 year after EIT, 3 hips had cup and stem revision and 1 hip had isolated cup revision, leaving 46 hips for clinical assessment. No complications were noted. mHHS improved by 26 ± 19 (P < .001) and OHS improved by 20 ± 11 (P < .001). Twenty-six hips (57%) achieved the patient acceptable symptom state for mHHS, whereas 42 hips (91%) achieved the patient acceptable symptom state for OHS. Post-tenotomy groin pain was slight in 15%, mild in 17%, and moderate in 11%. Regression analyses revealed no associations between clinical scores and overhang/anteversion. For patients with iliopsoas tendinopathy following THA, endoscopic iliopsoas tenotomy granted clinically important improvements of mHHS in 76% and OHS in 89%, despite moderate residual groin pain in 11%. Improvements in clinical scores did not seem to be associated with the extent of cup overhang or anteversion in the cases for which adequate preoperative imaging was available. Level IV, retrospective cohort study.

Multiple Instability Events at Initial Presentation Are the Major Predictor of Failure of Nonoperative Treatment for Anterior Shoulder Instability

To define the success rate of initial nonoperative treatment for traumatic anterior shoulder instability in a defined U.S. geographic population, describe factors that predict conversion to surgery after initial nonoperative management, and describe the long-term outcomes of nonoperative treatment after the index traumatic anterior instability event. The Rochester Epidemiology Project database was used to identify patients aged 14 to 39 years treated for anterior shoulder instability between 1994 and 2016. Patient demographic characteristics, comorbidities, injury characteristics, and imaging were evaluated. Patients treated nonoperatively for the first 6 months after the index instability event were analyzed to determine long-term outcomes (recurrence rate, pain at last follow-up, radiographic outcomes), the success rate of continued nonoperative treatment (no conversion to surgery), and factors associated with conversion to surgery (patient and injury characteristics). Survivorship free of surgery was reported with a Kaplan-Meier survival curve, and Cox proportional hazards models were used to evaluate association of variables with conversion to surgery. A total of 379 patients met the study criteria, with an average follow-up period of 10.2 years (range, 0.53-25.00 years). The average age was 23.9 years, the mean body mass index was 26.2, and 100% of instability events were due to trauma. Of the shoulders, 79 (20.1%) ultimately failed initial nonoperative treatment and progressed to surgery. At final follow-up, the rate of recurrent instability was 52.3% in the group treated definitively without surgery, and the recurrence rate decreased from 92.4% to 10.1% in patients who underwent conversion to surgical treatment. Factors associated with conversion to surgery included 2 or more subluxations prior to the first evaluation (hazard ratio [HR], 1.82; P= .002), 2 or more dislocations prior to the first evaluation (HR, 1.76; P= .006), and recurrent instability at follow-up (HR, 4.21; P < .001). Most patients younger than 40 years with shoulder instability who were initially treated nonoperatively for 6 months were definitively treated without surgery. Ultimately, 35% of these patients experienced recurrent dislocations after 6 months of conservative treatment and 20% underwent surgical treatment. In most patients who underwent conversion to surgical treatment, surgery was performed within 12.5 years of their first instability event. Patients who experienced multiple instability events before or after consultation were more likely to undergo conversion to surgery after initial nonoperative management. Level III, retrospective database review.

Bilateral Osteochondritis Dissecans of the Talar Posterior Calcaneal Articular Surface in a Professional Soccer Player: A Case Report

Introduction:Preferred sites of osteochondritis dissecans (OCD) are the distal femur and humerus, and the dome of the talus. We report a rare case of a professional soccer player with bilateral OCD of the talar posterior calcaneal articular surface.Case Report:The left talus showed a loose but not displaced fragment, and pain was relieved with 3 months of conservative treatment. The right had two loose fragments that were displaced from their beds in the talar posterior calcaneal articular surface. The loose bodies were surgically excised. The player remains symptom free 4 years after the operation and participates in professional games. Thus, although OCD of the talar posterior calcaneal articular surface remains a relatively uncommon injury, we suggest that treatment methods tailored to the OCD stage as per Berndt and Harty classification may be successful. The exact causes and establishment of a treatment protocol in these cases will depend on the investigation of future cases.Conclusion:Since this case of OCD of the talar posterior calcaneal articular surface was bilateral, we hypothesized that it may have been caused by microtrauma in the sense of repetitive, excessive compression of the subchondral bone, or by a vascular etiology.

Surgical treatment for insertional Achilles tendinopathy and retrocalcaneal bursitis: more than 1 year of follow-up.

ObjectiveTo analyse the imaging changes in bone marrow oedema of the calcaneal prominence, retrocalcaneal bursa and degenerative Achilles tendon after the surgical treatment of insertional Achilles tendinopathy (IAT).MethodsThis retrospective study analysed patients with IAT and retrocalcaneal bursitis that were diagnosed based on their symptoms and radiographic and magnetic resonance imaging (MRI) examinations. For patients that had received 3 months of conservative treatment but still presented with symptoms, arthroscopic debridement of the retrocalcaneal bursa and resection of calcaneal prominence were undertaken. Patients with degeneration of the Achilles tendon underwent debridement of Achilles tendon calcification with an open incision. The last follow-up included radiographic and MRI imaging, Visual Analogue Scale (VAS) pain scores and American Orthopedic Foot and Ankle Society (AOFAS)-Ankle and Hindfoot scores.ResultsThirty patients were included (mean ± SD follow-up, 3.1 ± 0.5 years). The VAS pain and AOFAS-Ankle and Hindfoot scores were significantly improved after surgery. MRI showed that bone marrow oedema of the calcaneal prominence and the retrocalcaneal bursa was significantly reduced compared with preoperative values. There was no significant change in the high signal area of the IAT.ConclusionSurgical treatment of IAT and retrocalcaneal bursitis effectively alleviated local pain and restored function.

Patient-led use of patient-reported outcome measure in self-Management of a Rotator Cuff Injury

IntroductionThe patient is the person who experiences both the processes and the outcomes of care. Information held by the patient is vital for clinical and self-management, improving health outcomes, delivery of care, organization of health systems, and formulation of health policies. Patient-reported outcome measures (PROMs) play an important role in supporting patient’s self-management. This narrative describes a patient-led use of a PROM to self-manage after a rotator cuff injury.MethodsThis is a narrative of a patient who tore the supraspinatus tendon in her right shoulder in an accident. The Disabilities of the Arm, Shoulder and Hand, the DASH questionnaire, was used to monitor and self-manage recovery after the accident.The DASH questionnaire is a self-reported questionnaire that measures the difficulty in performing upper extremity activities and pain in the arm, shoulder or hand. It has been widely used in research studies, but here the patient initiated its use for self-management while waiting for and after rotator cuff surgery. The patient created separate sub-scale scores for function and for pain to answer questions from healthcare providers about her recovery.ResultsThere was noticeable improvement over 3 months of conservative treatment, from a high level of disability of 56 to 39 (score changed 17); however, the scores were nowhere near the general population normative score of 10.1. Surgery improved the score from 39 pre-surgery to 28. Post-surgical interventions included physiotherapy, pain management and platelet-riched plasma treatment (PRP). The score was 14 4 weeks post-PRP.ConclusionsThe patient found the DASH useful in monitoring recovery from a rotator cuff injury (before and after surgery). The DASH contributed to communication with healthcare professionals and supported the clinical management. The DASH questionnaire was able to capture the patient’s experience with the injury and surgical recovery, corroborating an improvement in function while there was persistent post-surgical pain.

Open Versus Arthroscopic Treatment of Chronic Lateral Epicondylitis and Worker’s Compensation

PurposeTo compare the short-term outcomes between arthroscopic and open procedures for the treatment of lateral epicondylitis. Because a significant portion of patients have worker’s compensation (WC), the outcomes in these subgroups were separately analyzed. MethodsA retrospective analysis of patients who had surgical treatment of lateral epicondylitis by a single surgeon from 2010 to 2017 was performed. Patients who were symptomatic after 9 months of conservative treatments including nonsteroidal medications, steroid injections, and physical therapy were offered surgical intervention. The type of surgery was selected after detailed consultation with the patient. Charts were reviewed for preoperative pain, grip strength as measured by dynamometer, smoking status, and WC status. Postoperative assessments included pain and grip strength at 6 weeks and time taken to return to full duty. Two groups were compared using unpaired t test and chi-squared tests. Results were compared with similar studies in the literature. ResultsThe study included 30 patients in the arthroscopic debridement group and 42 patients in the open tenotomy and reinsertion group. Eighteen patients (25%) had WC. Compared with the open group, the arthroscopic group had earlier return to full duty (mean 7.13 weeks, confidence interval [CI] 6.21 to 8.05 versu mean of 12.22 weeks, CI 11.21 to 13.24; P < .001) and less time for complete pain relief (mean 7.4 weeks, CI 7.02 to 7.93 versus 9.5 , CI 8.68 to 10.44; P = .043). No difference was seen among the groups in terms of unfavorable outcome (persistent pain and recurrence of pain), JAMAR hand dynamometer score at 6 weeks, and visual analog score at 6 weeks. A total of 11 patients (15%) had unfavorable outcome. Incidence of unfavorable outcomes was more in patients with WC insurance (36% in WC versus 7% in non-WC; P = .023). No association was seen with smoking status. WC patients also had a longer time to return to full duty (16.68 weeks for WC versus 7.65 weeks for non-WC; P < .001) and a longer time to get complete pain relief (12.4 weeks for WC versus 7.5 weeks for non-WC; P < .001). ConclusionThe arthroscopic technique offers advantages of earlier return to work and shorter recovery period along with additional advantages of joint inspection and ability to treat coexisting pathologies. WC patients had a longer time to return to full duty and time for complete pain relief. Level of EvidenceLevel III, retrospective comparative study.

Allogeneic mesenchymal precursor cells treatment for chronic low back pain associated with degenerative disc disease: a prospective randomized, placebo-controlled 36-month study of safety and efficacy

BACKGROUND CONTEXT PURPOSEEvaluate the safety and efficacy of a single intradiscal injection of STRO-3+ adult allogeneic mesenchymal precursor cells (MPCs) combined with hyaluronic acid (HA) in subjects with chronic low back pain (CLBP) associated with degenerative disc disease (DDD) through 36-month follow-up. STUDY DESIGN/SETTINGA multicenter, randomized, controlled study conducted at 13 clinical sites (12 in the United States and 1 in Australia). SUBJECT SAMPLEA total of 100 subjects with chronic low back pain associated with moderate DDD (modified Pfirrmann score of 3–6) at one level from L1 to S1 for at least 6 months and failing 3 months of conservative treatment, including physical therapy were randomized in a 3:3:2:2 ratio to receive 6 million MPCs with HA, 18 million MPCs with HA, HA vehicle control, or saline control (placebo) treatment. OUTCOME MEASURESSubjects were clinically and radiographically evaluated at 1, 3, 6, 12, 24, and 36 months postinjection. Subject-reported outcomes including adverse events, LBP on a Visual Analog Scale (VAS), Oswestry Disability Index (ODI), SF-36 and Work Productivity and Activity Index were collected. METHODSClinical and radiographic measures were collected at each visit. All randomized subjects were included in the safety assessments and analyzed based on the treatment received. Safety assessments included assessments of AEs, physical and radiographic examinations and laboratory testing. Efficacy assessments evaluated changes in VAS, ODI, and modified Pfirrmann (MP) scores between all active and control groups, respectively. Assessments included least squares mean (Mean), LS mean change from baseline (Mean Change) and responder analyses in order to assess the clinical significance of observed changes from baseline. The population for efficacy assessments was adjusted for the confounding effects of post-treatment interventions (PTIs). This study was conducted under an FDA Investigational New Drug application sponsored and funded by Mesoblast. RESULTSThere were significant differences between the control and MPC groups for improvement in VAS and ODI. The PTI-corrected VAS and ODI Means and Mean Change analyses; the proportion of subjects with VAS ≥30% and ≥50% improvement from baseline; absolute VAS score ≤20; and ODI reduction ≥10 and ≥15 points from baseline showed MPC therapy superior to controls at various time points through 36 months. Additionally, the proportion of subjects achieving the minimally important change and clinically significant change composite endpoints for the MPC groups was also superior compared with controls at various time points from baseline to 36 months. There were no significant differences in change in MP score from baseline across the groups. There were also no statistically significant differences in change in modified MP score at the level above or below the level treated between study arms. Both the procedure and treatment were well tolerated and there were no clinical symptoms of immune reaction to allogeneic MPCs. There was a low rate of Treatment Emergent Adverse Events (TEAEs) and Serious Adverse Events, and the rates of these events in the MPC groups were not significantly different from the control groups. One TEAE of severe back pain was possibly related to study agent and one TEAE of implantation site infection was considered to be related to the study procedure. CONCLUSIONSResults provide evidence that intradiscal injection of MPCs could be a safe, effective, durable, and minimally invasive therapy for subjects who have CLBP associated with moderate DDD.

Isolated Intermetatarsal Ligament Release as Primary Operative Management for Morton's Neuroma: Short-term Results.

Although the precise pathoetiology of Morton's neuroma remains unclear, chronic nerve entrapment from the overlying intermetatarsal ligament (IML) may play a role. Traditional operative management entails neuroma excision but risks unpredictable formation of stump neuroma. Medical records were examined for adult patients who failed at least 3 months of conservative treatment for symptomatic and recalcitrant Morton's neuroma and who then underwent isolated IML decompression without neuroma resection. A total of 12 patients underwent isolated IML decompression for Morton's neuroma with an average follow-up of 13.5 months. Visual Analog Pain Scale averaged 6.4 ± 1.8 (4-9) preoperatively and decreased to an average of 2 ± 2.1 (0-7) at final follow-up (P = .002). All patients reported significant improvement. Isolated IML release of chronically symptomatic Morton's neuroma shows promising short-term results regarding pain relief, with no demonstrated risk of recurrent neuroma formation, permanent numbness, or postoperative symptom exacerbation. Level IV: Case series.

Chronic lateral ankle instability: Results of two-staged approach, correlation with magnetic resonance imaging findings, and incidence of associated pathologies – A 4-year follow-up study

Objectives: About 20% of ankle sprains have persistent symptoms even after 6 weeks–3 months of conservative treatment of physiotherapy and bracing. We followed a two-staged operative treatment protocol for the management of patients with persistent chronic lateral ankle instability. This study aims to analyze the outcomes of this two-staged treatment protocol and also to compare the magnetic resonance imaging (MRI) and arthroscopic findings in such patients and note the presence of associated pathologies. Materials and Methods: This is a retrospective study of 87 patients operated for chronic lateral ankle instability in two stages: (1) Diagnostic examination under anesthesia and ankle arthroscopy and (2) modified Brostrom procedure. Results: With a mean follow-up of 4 years, 31% of the patients had a complete resolution of their symptoms 4 months after the first procedure. Mean American Orthopaedic Foot and Ankle Score (AOFAS) and visual analog scale (VAS) scores show a significant improvement in functional outcomes in both the groups (P &lt; 0.05). Moreover, the MRI findings were equivocal or false negative in 60% of the patients. We also observed associated pathologies such as synovitis, osteochondral defect of talus, and anterolateral impingement in 40% of the patients. Conclusion: The two-staged treatment of ankle arthroscopy and modified Brostrom procedure is highly effective in resolution of the symptoms of patients with chronic lateral ankle instability. As MRI is not very sensitive and because of the associated intra-articular lesions found in this spectrum of patients, a primary ankle arthroscopy followed by a staged Brostrom procedure has shown to improve outcomes significantly with optimal intervention.

Endoscopic Assisted First Rib Resection for Thoracic Outlet Syndromes in Overhead Throwing Athletes

Objectives:Thoracic outlet syndrome (TOS) is a complex of signs and symptoms resulting from compression of the nerves and vessels supplying the upper limb. Repetitive and cumulative stress of the upper extremity in athletes are associated with TOS. Despite of several previous reports, TOS is incompletely understood, difficult to diagnose, and often poorly managed. Especially, etiology and pathology on throwing athletes with TOS have not been still unknown. Recent articles showed that with the help of the endoscope, more safety and less invasive surgery has been achieved. We consider that intraoperative observations will lead to analyses the pathology of TOS in athletes. The purpose of this retrospective study was to investigate characteristic clinical features, objective imaging, intraoperative findings, and surgical outcomes of patients with TOS in overhead throwing athletes.Methods:This study analyzed 158 cases of TOS (47 women and 111 men) who underwent endoscopic assisted first rib partial resection. Patients were divided into 2 group: athletes (89 patients) and non-athletes (69 patients). The diagnosis of TOS was based on clinical features, plane radiographs, ultrasonography, three-dimensional computed tomography angiography, and MRI. Indications for this surgery included failure of more than 6 months of conservative treatment or evidence on artery interruption on 3D angiography or obvious narrowing of interscalene region on ultrasound. Conventional transaxially approach described by Roos with endoscopic assist was underwent for partial resection of the first rib and decompression of neurovascular bundle. Intraoperative findings involved as follows; Interscalene distance (ISD): the distance between the posterior edge of the anterior scalene and the anterior edge of the middle scalene, Neurovascular bundle (NVB) patterns: based on alignment of the nerve, artery, and vein, following three types; parallel type, oblique type, and vertical type. Evaluation was performed through use of the clinical rating system of Roos’s classification, DASH, intraoperative endoscopic findings, plain radiographs, and ultrasonography. The mean follow-up period was 17.4 (from 6.4 to 42.4) months.Results:We found characteristic clinical features in athletes with TOS compared with non-athletes as follows; younger (16.7 years vs 36.3 years), shorter duration of symptoms (7.8 vs 26.0), and better outcomes (excellent or good percentage in Roos score; 91.0 % vs 73.9 %). Intraoperative findings showed no significant differences of ISD and NVB patterns between athletes and non-athletes. On the other hand, anatomical variation including abnormal bundle was found more frequently in athletes compared with non-athletes (Figure 1, Table1). There were no major complications.Conclusions:In conclusion, endoscopic assisted transaxially approach for first rib resection in TOS provided a superior magnified clear visualization and safely sufficient decompression of neurovascular bundle. The current study showed better clinical outcomes in athletes compared with non-athletes. Several factors including younger, shorter duration of symptoms, and anatomical variation would reflect to the result. The orthopaedic surgeon should be aware of the possibility of TOS in an adolescent who plays an overhead throwing sport. Appropriate surgical indication would provide them superior clinical outcomes.

Osteochondral injury of the femoral insertion of the deep medial collateral ligament of the knee-is there asuccessful surgical treatment?

Isolated ruptures of the deep portion of the medial collateral ligament (MCL) without clinical instability can mostly be treated conservatively with good clinical results. A10-year-old girl was initially also treated conservatively. As symptoms of pain and limited range of motion were not resolved after 3months of conservative treatment and although there were no signs of instability, it was decided to proceed with the surgical intervention. A small osteochondral fragment on the femoral insertion of the deep MCL (medial meniscofemoral ligament) was removed and the soft tissue portion of the ligament was reinserted in the anatomical footprint. The patient showed complete resolution of the pain and afull range of motion of the knee joint. At the last follow-up 18months after surgery the patient was completely free of symptoms.

Conservative or surgical treatment of carpal tunnel syndrome based on the severity and patient risk factors.

The carpal tunnel syndrome (CTS) is the most common median nerve compression disease which may result in impaired nerve function. This study was carried out to determine which treatment is more appropriate for moderate or severe CTS patients with or without risk factors. In a cohort prospective study, the patients with moderate CTS received a conservative treatment including night splint for 3months, one methyl prednisolone injection whereas patients with severe CTS underwent surgical release. They were followed for 1year using the bland scale based on the electromyography and nerve conduction velocity studies and five-point global assessment outcome scale. Totally, 68 moderate CTS cases (32 patients with risk factors and 36 without any risk factors) and 32 cases with severe CTS (16 patients with risk factors and 16 without any risk factors) were assess at 6months and 1year following the treatment. Although about 22% of moderate CTS patients with risk factors changed to mild CTS after 6months of conservative treatment, about 75% showed mild CTS or complete remedy following 1year (Pvalue < 0.001). This result was about 30% at 6 months and about 95% at 1year following conservative treatment in patients with moderate CTS without risk factors. None of moderate CTS patients with or without risk factors underwent surgery after 1year of follow-up. Although almost all patients with severe CTS, with and without risk factors, showed complete recovery or changed to mild CTS at 1year postoperatively, the result was statistically significant for cases without risk factors (Pvalue = 0.002). Conservative treatment for moderate CTS would be a good option, and the final result may be seen 1year later; however, its positive effect is quicker and better for moderate CTS cases without risk factors. Surgical release of the carpal tunnel may be the best choice not only for severe CTS cases with risk factors but also for cases without risk factors. For obtaining consistent rapid result, it is recommended to do surgical release for all cases of moderate or severe CTS without considering risk factors, but more clinical researches are needed. II.