Months Of Conservative Treatment Research Articles

Is the duration of pre-operative conservative treatment associated with the clinical outcome following surgical decompression for lumbar spinal stenosis? A study based on the Spine Tango Registry.

The incidence of lumbar spinal stenosis (LSS) continues to rise, with both conservative and surgical management representing options for its treatment. The timing of surgery for LSS varies from shortly after the onset of symptoms to several months or years after conservative treatment. The aim of this study was to investigate the association between the duration of pre-operative conservative treatment and the ultimate outcome following surgical interventions for LSS. The study was based on prospective multicentre registry data (Spine Tango). Cases of LSS with a documented duration of conservative treatment, undergoing spinal decompression with at least one post-operative patient assessment between 3 and 30months, were included in the study. Cases of LSS with spondylolisthesis, additional spinal pathology or previous spinal surgery were excluded. Interrogation of the Spine Tango Registry listed 3478 patients meeting the prescribed inclusion criteria. This cohort was stratified into four groups: (1) no previous treatment (n=497; 14.3%), (2) conservative treatment <6months (n=965; 27.8%), (3) conservative treatment between 6 and 12months (n=758; 21.8%), and (4) conservative treatment >12months (n=1258; 36.1%). Group 4 reference group in regression analysis. The inverse probability of treatment weighting (IPTW) was applied using the propensity score to balance the groups for their characteristics. Outcome measures included achievement of the minimum clinically important change (MCIC) score of 2 points for (a) back pain, (b) leg pain and (c) Core Outcome Measures Index (COMI), and (d) surgical complications, (e) general complications and (f) operation time >2h. Patient group ("duration of conservative therapy") was not associated with achievement of the MCIC for post-operative relief of leg pain (p=0.22), achievement of MCIC for the COMI score (p=0.054), surgical complications (p=0.11) or general complications (p=0.14). Only MCIC for post-operative relief of back pain (p=0.021) and operation time were significantly associated with patient group (p=0.038). However, compared with the reference group of >12months of conservative treatment there was no significant difference in the likelihood of achieving the MCIC for those with none, <6 or 6-12months of conservative treatment. The duration of pre-operative conservative treatment was not associated with the ultimate outcome of decompression surgery. Further research is required to investigate optimal thresholds/indications for surgery and its appropriate timing in individual patients.

Z-plasty of the flexor hallucis longus tendon at tarsal tunnel for checkrein deformity.

To review the outcome of Z-plasty of the flexor hallucis longus (FHL) tendon at the tarsal tunnel for checkrein deformity in 8 patients. Records of 6 males and 2 females aged 14 to 67 (mean, 39.5) years who underwent Z-plasty (lengthening) of the FHL tendon at the tarsal tunnel for checkrein deformity in the first and second toes by a single surgeon were reviewed. All patients had undergone 3 months of conservative treatment. The mean time from injury to surgical treatment was 8.4 (range, 5-12) months. All patients had associated injuries including distal tibiofibular fracture (n=6), distal fibular fracture (n=1), and crush injury aroundthe ankle (n=1); they were treated with intramedullary nailing (n=6), long leg splinting (n=1), and short leg splinting (n=1). After a mean follow-up of 3.4 (range, 1-7) years, the FHL tendon was lengthened by a mean of 1.7 (range, 1.6-1.8) cm, and the mean American Orthopedic Foot and Ankle Society hallux score increased from 59 (range, 52-67) to 89 (range, 80-90). No patient had recurrence, nerve injury, or tarsal tunnel syndrome, although one patient had sensory disturbance of the posterior tibial nerve in the forefoot, which resolved spontaneously at week 2. Z-plasty of the FHL tendon at the tarsal tunnel is a viable option for correction of checkrein deformity.

Polydeoxyribonucleotide Injection in the Treatment of Chronic Supraspinatus Tendinopathy: A Case-Controlled, Retrospective, Comparative Study With 6-Month Follow-Up

ObjectiveTo determine the efficacy of polydeoxyribonucleotide (PDRN) injection for rotator cuff disease (RCD). DesignCase-controlled, retrospective, comparative study. SettingOutpatient clinic at a university-affiliated tertiary care hospital. ParticipantsPatients (N=106) with chronic nontraumatic refractory RCD who were unresponsive to at least 1 month of conservative treatment: 55 patients received PDRN injection (PDRN group) and 51 continued conservative treatment (control group). InterventionsNot applicable. Main Outcome MeasuresShoulder Pain and Disability Index, score on a visual analog scale of the average shoulder pain level, number of analgesic ingestions per day, isometric strength of shoulder abductor, active range of motion (flexion, abduction, internal rotation, external rotation), and maximal tear size of tendon on ultrasonography at pretreatment and 3 and 6 months postinjection. ResultsThere was no significant difference between the 2 groups in terms of age, sex, shoulder affected, duration of symptoms, and ultrasonographic findings at pretreatment. Compared with the control group, the treatment group showed a significant improvement in Shoulder Pain and Disability Index, visual analog scale score, and number of analgesic ingestions per day. However, there was no difference in isometric strength, active range of motion, and maximal tear size of tendon. No adverse events were reported. ConclusionsTo our knowledge, this is the first study to assess the efficacy of PDRN injection for patients with RCD. The PDRN injection group showed improvement in pain and subjective disability in patients with RCD and continued to show improvement for 3 months thereafter; the PDRN injection can be an optional treatment for patients with chronic RCD who show no response to other treatments.

Novel Surgical Technique for Bone Marrow Lesion — Case Report

Abstract Introduction: Bone marrow lesions (BMLs) are commonly described as magnetic resonance imaging (MRI) findings associated with stress injuries or trauma. The presence of BMLs closely correlates with pain and rapid joint deterioration. Case presentation: A 51-year-old healthy man presented to our clinic with severe knee pain due to BMLs. After 3 months of conservative treatment, arthroscopy and subchondroplasty (SCP) of the medial femoral condyle was performed. The IKDC (International Knee Documentation Committee) score improved from 39.9 to 66.7 at 6 months, and to 87.4 at 1 year after surgery. The KOOS (Knee Injury and Osteoarthritis Outcome) score improved from 38.5 to 77.7 at 6 months, and to 92.6 at 1 year after surgery. The Tegner Lysholm score improved from 23 to 80 at 6 months, and to 95 at 1 year after surgery. Conclusion: SCP may provide a viable approach to reduce pain associated with BML, with minimal risk of significant complications.

Life-threatening paraspinal muscle hematoma after percutaneous vertebroplasty.

Bleeding and hematoma formation is rarely reported in percutaneous vertebroplasty procedure. An 84 year old male presented with a large paraspinal muscle hematoma after a percutaneous vertebroplasty. The patient had neither any prior bleeding disorder nor any anticoagulant treatment. Vital signs of the patient were unstable, and his hemoglobin level decreased daily. After a month of conservative treatment, including transfusion, cryotherapy, pain control and bed rest, his hemoglobin level remained stable and he showed relief from pain. Four months later, hematoma resolved spontaneously and he could walk without back pain.

Application of Laparoscopic Lumbar Discectomy and Artificial Disc Replacement: At Least Two Years of Follow-Up.

This prospective observational study included 22 patients who were diagnosed with symptomatic degenerative disc disease treated via artificial disc replacement (ADR) with a laparoscopic technique. The current study aimed to assess the safety and efficacy of ADR using a laparoscopic technique for lumbar disc herniation. Symptomatic degenerative disc disease is the major cause of low back pain with lumbar segmental instability. ADR has increased in popularity as an alternative treatment for lumbar disc herniation. However, the traditional approach to spinal surgery carries the risk of catastrophic bleeding from injury to major vessels, as well as iatrogenic injury to the viscera and associated structures. Therefore, laparoscopic lumbar discectomy and ADR may represent a useful alternative. Twenty-two patients (8 males and 14 females) who were diagnosed with symptomatic degenerative disc disease were included in this study. Seven cases involved the L4/5 level, and 15 cases involved the L5/S1 level. All patients were ineffective after at least 6 months of conservative treatments; all patients were informed of the surgery before the operation and provided consent. Three-dimensional computed tomographic angiography (3D-CTA) of the iliac great blood vessels was completed before the surgery. All surgical procedures were performed under a laparoscope. All patients were followed up. All surgeries were successfully completed. The average operation time was 120 minutes (range 110-150 min), and the average hemorrhage was 145 mL (range 80-360 mL). All cases underwent X-rays at 3 days, 3 months, 6 months, 1 year, and the final postoperative follow-up. The outcome indicated that there was no mobilization, displacement, or subsidence in all patients with the exception of one case with prosthesis migration. The follow-up time was 43.8 months (range 24-64 months). The mean visual analog scale (VAS) and Oswestry scores were decreased postoperatively. The mean improvement rate of the VAS score was 73.5%. Lumbar ADR using a laparoscope represents a novel, minimally invasive treatment for symptomatic degenerative disc disease and severe lumbar discogenic pain.

Outcomes of arthroscopic lateral epicondylitis release: Should we treat earlier?

BackgroundWhen managed conservatively, lateral epicondylitis often subsides only after considerable time, during which social and occupational activities are severely disrupted. If conservative management fails, a recently introduced option is arthroscopic release of the extensor carpi radialis brevis (ECRB). The primary objective of this study was to compare clinical outcomes of this procedure according to preoperative symptom duration. HypothesisEarlier arthroscopic release is associated with better functional outcomes. Material and methodConsecutive patients with arthroscopically managed lateral epicondylitis were included in a retrospective study. Arthroscopy was performed only after at least 6 months of conservative treatment. The criteria to evaluate the clinical outcomes were the Nirschl and Quick-DASH scores, muscle strength, time to pain relief, and percentage of functional recovery. ResultThirty-five patients were evaluated at a median of 4 years (range: 1–12 years) after surgery. Mean preoperative symptom duration was 18 months (range: 6–106 months) with a mean sick leave duration of 2.3±4.9 months. Postoperatively, mean time to recovery was 37.5 days (range: 7 days to 5 years) and mean sick leave duration was 2.4±2.4 months. The mean Quick-DASH score was 15.9±19.1. The Nirschl score improved significantly, from 26.4±7.9 to 66.3±16.3. The initial muscle strength deficit was 10.1±33.2% and muscle strength at last follow-up was increased by 4.3±30.3%. Symptom duration showed no correlations with any of the clinical outcome measures. Discussion and conclusionsOutcomes after arthroscopic release were not associated with symptom duration in this study. Nevertheless, the good clinical outcomes support treatment with arthroscopic release after only 6 months of conservative management. Level of evidenceIV, retrospective study.

Use of pain drawing as an assessment tool of sciatica for patients with single level lumbar disc herniation.

The objectives of this study were to examine the diagnostic accuracy of pain drawing (PD) in determining the level of involvement and to investigate how the quantitative evaluation results of PD using a grid score (GS) correlates with the results of other clinical evaluation measures in diagnosis and assessment of patients with lumber disc herniation (LDH) involving a single nerve root. Thirty-one patients with single level LDH who were diagnosed and conservatively treated by the first author constituted the study population. In order to assess the diagnostic accuracy of PD, the level of involvement as determined by PD was compared to the final diagnosis. In 26 of the 31 patients who could be followed for more than 6 months of conservative treatment, the GS in PD evaluation was compared to the score assessed by the Japanese Orthopaedic Association scoring system for low back pain (JOA score) and the visual analog scale (VAS) both before and after the treatment. The overall diagnostic accuracy of PD for the determination of the affected level averaged 68.8 %, and the accuracy was higher at the L4/5 and L5/S levels than the L2/3 and L3/4 levels. The average values of VAS and GS significantly decreased and the JOA score significantly improved after the treatment. Moreover, a significant correlation was demonstrated between the scores derived from these three evaluation measures. The present study indicated the potential usefulness of PD in clinical assessment during the treatment course.

Arthroscopic subacromial decompression

Coracoacromial ligament release to widen the subacromial space, resection of the anterior undersurface of the acromion and, if needed, caudal exophytes at the acromioclavicular joint. All types of outlet impingement after 3months of conservative treatment. Impingement syndrome with instability/muscular imbalance, massive rotator cuff tear, unstable os acromionale, posterior-superior impingement, joint infection, freezing phase of asecondary frozen shoulder. Lateral decubitus position with traction device for the arm. Diagnostic arthroscopy of the glenohumeral joint via standard portals. With arthroscope moved to the subacromial space, bursectomy, electrosurgical release of coracoacromial ligament, resection of acromial hook through standard posterior portal. Physiotherapy or self-exercises on postoperative day1, pain-adapted analgesia to avoid shoulder stiffness. Several studies present positive long-term results compared to conservative treatment (and open acromioplasty) for partial rotator cuff tears and for elderly patients. With a 20-year follow-up, successful results have been achieved for all patients with isolated impingement syndrome.

THE PECULIARITIES OF HIP ARTHROPLASTY UNDER THE CONDITIONS OF CONGENITAL HIP DISLOCATION IN ADUL TS

The goal: to optimize the tactics of total hip replacement (THR) under the conditions of congenital hip dislocation in adults. Methods: the results of THR in 11 patients (8 females, 3 males) with congenital hip dislocation Crowe IV type. The age of patients amounts from 15 to 57 years (37.4 years in average). 12 operations THR were performed. One patient underwent THR on both hips. An acetabular component was implanted on the place of true acetabulum in all cases. For 6 patients with more than 4 cm shortening of lower extremity THR was performed only after brining down of femoral head on the level of pure acetabulum using external fixator. In the case of bilateral hip dislocation THR procedure was performed on both sides with shortening osteotomies of proximal femurs that prevented biomechanical discrepancy of the lower extremities. Stem of endoprosthesis was selected according to the shape of intramedullar cavity of proximal femur in all cases. The results of treatment were observed from 6 months to 10 years. Average score according to Harris scale increased by 38.3 points. Healing of postoperative wounds was by the first intention. The bone grafts rearranged and played the role of acetabulum dome. The complications were observed in 2 cases. One patient with the shortening of 4.5 cm underwent THR simultaneously with extremity elongation. A sciatic neuritis was observed after the operation. The function of extremity was restored after 6 months of conservative treatment. Another case was associated with purulent complication that caused operative wound revision without removal of endoprothesis.

Cross-cultural adaptation and validation of the Italian version of the Western Ontario Osteoarthritis of the Shoulder index (WOOS).

BackgroundThe Western Ontario Osteoarthritis of the Shoulder index (WOOS) has been introduced as a disease-specific quality of life measurement in patients with glenohumeral arthritis. The aim of the present study was to perform a cross-cultural adaptation of the English version of the WOOS to Italian and to assess its validity, reliability and responsiveness in patients with glenohumeral joint osteoarthritis treated conservatively.Material and methodsThe adaptation process was carried out following the simplified Guillemin criteria. The English version was translated into Italian by two bilingual orthopaedic surgeons and then translated back into English by two different bilingual orthopaedic surgeons. The original version was compared with the back-translation. The questionnaire was prospectively administered to 30 patients with glenohumeral osteoarthritis at baseline and again after 5 days for retest reliability. After 6 months of conservative treatment, the responsiveness of the questionnaire was assessed in a subsample of 20 patients. The level of statistical significance was set at 0.05.ResultsThe interclass correlation coefficient between test and retest of the WOOS was 0.99 (P < 0.001). Pearson’s correlation coefficient between the WOOS and disability of the arm, shoulder and hand (DASH) preoperatively was 0.73 (P < 0.01) and the correlation between the changes of score for the WOOS and DASH was 0.75 (P < 0.01). There were no floor or ceiling effects. Responsiveness, calculated by standardized response mean, was 1.1 and effect size was 1.3.ConclusionsThe Italian version of the WOOS questionnaire has shown to be equivalent to its English version and demonstrated good validity, reliability and responsiveness to conservative treatment of glenohumeral osteoarthritis.Level of evidenceLevel II.Electronic supplementary materialThe online version of this article (doi:10.1007/s10195-016-0400-4) contains supplementary material, which is available to authorized users.

How to cope with insufficient pneumoperitoneum and exposure when performing laparoscopic gastric bypass surgery.

Despite following international guidelines and conducting routine preoperative dietary counseling, every bariatric surgeon will encounter technical challenges in laparoscopic gastric bypass surgery. We present a series of patients in whom the bariatric procedure was stopped after encountering insufficient exposure during diagnostic laparoscopy. These patients were sent back for dietary counseling and underwent surgery after conservative weight loss. The data from this two-step procedure are analyzed and discussed. This concept was applied and studied in 14 patients from a series of 620 bariatric procedures. Patients who underwent a primary laparoscopic gastric bypass (n = 593) were used as references. The patients in the study group were significantly heavier than those in the reference group (165 vs. 127kg, p < 0.001), with 79% having a BMI >50kg/m(2). The patients lost a median of 11kg after 2months of conservative treatment, and the mean BMI decreased from 55.7 to 52.6kg/m(2). All the patients in the study group underwent laparoscopic surgery for the second procedure with no need for conversion. The complication rate was not elevated in the study group. Overall hospital costs were higher for the study group compared with those for the primary laparoscopic bypass group (27,136 vs. 19,601 USD, p = 0.034). The primary laparoscopic procedure can be stopped in patients with insufficient exposure instead of having them undergo conversion to open surgery. These patients may undergo successful laparoscopic procedures after conservative weight loss with no increased risk and with all of the possible benefits of a laparoscopic approach. As a result of this study, we have established a fixed, preoperative lower limit of 10% excess weight reduction before accepting superobese patients (BMI >50kg/m(2)) for surgery at our hospital.

Non-operative Treatment for Extensive Skin Necrosis of a Neonatal Dorsal Foot caused by Extravasation

We herein describe two cases of non-surgical treatment for skin necrosis of the dorsum of the neonatal foot caused by extravasation. In both the cases, closure of the defects was achieved after 3 months of conservative treatment without any complications. Although the defects occupied almost all of the dorsal skin of the foot, no significant contracture disabling the toe or ankle occurred during the maximum follow-up period of 9 years. Non-surgical treatments could be an alternative treatment for neonatal skin necrosis caused by extravasation.

Nonsurgical Korean Integrative Treatments for Symptomatic Lumbar Spinal Stenosis: A Three-Armed Randomized Controlled Pilot Trial Protocol.

This is a study protocol for a pilot three-armed randomized controlled trial on nonsurgical integrative Korean medicinal treatment for symptomatic lumbar spinal stenosis (LSS). Thirty-six participants who have been diagnosed with (LSS) and recommended for spinal surgery by neurosurgeons or orthopedics and have had spinal symptoms such as severe low back pain and neurological claudication regardless of at least three months of conservative treatments will be recruited. Participants will be randomly assigned to be one of the three intervention groups, including the Mokhuri treatment program group 1 or 2 or usual care group. All treatments will be administered in inpatient units over a period of 4 weeks. The primary outcomes are 0 to 100 Visual Analogue Scales for low back pain and leg pain and the secondary outcomes are Oswestry Disability Index; EQ-5D; Roland-Morris Disability Questionnaire; Oxford Claudication Score; physical function test, including treadmill test, walking duration, and distance assessment for free leg pain; radiologic testing; and adverse events which will be assessed during the 4-week treatment period as well as after 3 and 6 months of follow-up. Then, we will assess the feasibility of the clinical trial design as well as a nonsurgical integrative treatment program. This trial is registered with CRIS registration number: KCT0001218.

Surgical Management of Recurrent Musculotendinous Hamstring Injury in Professional Athletes.

Background:Hamstring injury is the most common muscular lesion in athletes. The conservative treatment is well described, and surgical management is often indicated for proximal tendinous avulsions. To our knowledge, no surgical treatment has been proposed for failure of conservative treatment in musculotendinous hamstring lesions.Purpose:To describe the surgical management of proximal and distal hamstring musculotendinous junction lesions in professional athletes after failure of conservative treatment.Study Design:Case series; Level of evidence, 4.Methods:A consecutive series of 10 professional athletes, including 4 soccer players, 4 rugby players, and 2 handball players, underwent surgical intervention between October 2010 and June 2014 for the treatment of recurrent musculotendinous hamstring injuries. All athletes had failed at least 3 months of conservative treatment for a recurrent musculotendinous hamstring injury. Surgical resection of the musculotendinous scar tissue was performed using a longitudinal muscular suture. Lower Extremity Functional Scale (LEFS) and Marx scores were obtained at the 3-month follow-up, and a final phone interview was completed to determine recurrence of hamstring injury and return to previous level of play.Results:The mean age at surgery was 25.2 years (range, 19-35 years). The musculotendinous hamstring lesions involved 8 semitendinosus and 2 biceps femoris, with 6 injuries located proximally and 4 distally. Conservative treatment lasted a mean 5.1 months (range, 3-9 months) after last recurrence, and the patients had an average of 2.7 (range, 2-5) separate incidents of injury recurrence before surgical intervention was decided upon. At the 3-month follow-up, all patients had Marx activity scores of 16 and LEFS scores of 80. All 10 patients returned to the same level of play at a mean 3.4 months (range, 2-5 months). At a mean follow-up of 28.7 months, none of the athletes had suffered a recurrence. No surgical complication was encountered.Conclusion:In cases of failed conservative treatment of musculotendinous hamstring lesions, surgical intervention may be a viable treatment option in professional athletes and allows the patient to return to the same level of play.

The Effect of Low Dose Extracorporeal Shock Wave Therapy (ESWT) on Plantar Fasciitis: A Trial Study in Queen Mary Hospital: 低劑量體外衝擊波治療(ESWT)對足底筋膜炎的影響 - 在瑪麗醫院的試用研究

Background/PurposeTo assess the efficacy of low-energy extracorporeal shockwave therapy (ESWT) for the treatment of plantar fasciitis. MethodsThis was a prospective case series study that was performed at the Department of Orthopaedics, Queen Mary Hospital, Hong Kong. Twenty-one symptomatic feet in 16 patients with persistent symptoms of plantar fasciitis despite 3 months of conservative treatment were recruited in November 2008. All patients received five sessions of low energy ESWT and their corresponding 10-point visual analogue scale scores were recorded before and after each treatment sessions for each symptomatic foot. The patients were assessed for up to 6 months post-treatment. ResultsThe mean visual analogue scale scores reduction for pain on first step in the morning, daily activities, and heel compression test were 2.62 (44.3%), 3 (38.3%), and 1.6 (36.8%), respectively, post-treatment. The analgesic effect was maintained in 52.3% (n = 11) of the patients at 6 months post treatment. ConclusionLow energy ESWT was shown to be an effective outpatient treatment option for patients with plantar fasciitis.

Soft-Tissue Gas Can Signify Life-Threatening Conditions.

The appearance of gas on a diagnostic image usually grabs the immediate attention of an orthopaedist. Gas in the soft tissues can arise from gas-forming infectious organisms or from mechanical abnormalities caused by degenerative conditions or injuries. As this month’s “Case Connections” makes clear, when gas is observed in tissue, it’s crucial for clinicians to make early and definitive determinations of etiology, because some infections associated with this phenomenon can be very lethal very quickly. In the May 27, 2015 edition of JBJS Case Connector, Sakamoto et al. report on a thirty-three-year-old woman with a three-month history of shoulder pain who turned out to have a not-very-serious gas-containing ganglion cyst. Physical examination revealed moderate infraspinatus muscle atrophy. Radiographs appeared normal, but MRI showed a gas-containing cyst at the spinoglenoid notch that extended toward the posterosuperior aspect of the glenoid labrum. Nerve conduction studies revealed delayed conduction of the suprascapular nerve and decreased voluntary electrical potentials in the supraspinatus and infraspinatus muscles. Results of blood work were not suggestive of an inflammatory condition. After three months of conservative treatment, the pain and nerve dysfunction persisted, and the patient underwent open cyst excision and arthroscopic evaluation. The authors’ decision to do an open excision was based on concern that their patient’s condition might have had an infectious etiology. Arthroscopy revealed a partial detachment of the posterosuperior labrum from the glenoid, and the surgeons arthroscopically debrided the …

Anterior Knee Pain in a Casual Runner

HISTORY: 24 year old male runner initially presented with one year of left anterior knee pain. He denied any trauma, but first noticed a sharp pain during running and a dull ache afterwards. It had waxed and waned over the past year. Along with his anterior pain, he had noticed a decrease in the size of his thigh muscles. He denied any locking or catching, but did have the sensation of giving way and noticed a clunking when he flexed his knee. He was forced to decrease his activity level and was no longer able to run secondary to the pain. He had taken NSAID’s with minimal relief of his pain. He denied any prior injury to this knee. In addition to exercise, he noticed his pain with kneeling, stairs, and prolonged sitting. It had started to affect his overall quality of life. PHYSICAL EXAMINATION: VS: HR 67 BP 116/67 BMI 27.7. In general, he was well appearing. Knee examination showed no joint effusion or erythema, tenderness over the superior patella, and a palpable clunk with knee flexion and extension. He had FROM and a negative Apley’s test. DIFFERENTIAL DIAGNOSIS: 1. Patellofemoral Pain Syndrome 2. Synovial Plica 3. Quadriceps Tendinitis 4. Suprapatellar Bursitis 5. Suprapatellar Fat Pad Syndrome/Impingement TESTS AND RESULTS: X-ray of the Left Knee (4 views) showed no acute abnormalities. MRI of the Left Knee showed edema in the Suprapatellar Fat Pad, mild reactive change in the superior pole of the patella, mild intra tendinous signal in the quadriceps, and mild Grade 1 chondromalacia of the lateral patellar facet. FINAL/WORKING DIAGNOSIS: Suprapatellar Fat Pad Inflammation/Impingement TREATMENT AND OUTCOMES: He was seen 2 weeks after initial visit for MRI review, and he underwent injection of the suprapatellar fat pad with anesthetic and corticosteroid. He had resolution of his pain for one week, and subsequently increased his activity. However, his symptoms returned and remained refractory to a second injection. After three months of conservative treatment, he elected to pursue surgical management and underwent arthroscopic debridement of the suprapatellar fat pad. At two week post op follow up, he had good patellar mobility, some expected discomfort, and was continuing with PT. At six weeks, the clunking had resolved, he had graduated to a home exercise program, he was back walking without pain, and increased his activity once again.

Extracorporeal Shockwave Therapy for Refractory Greater Trochanteric Pain Syndrome

Introduction: Greater trochanteric pain syndrome (GTPS) is a common and disabling condition characterized by pain and tenderness at or around the trochanteric area. Extracorporeal shockwave therapy (ESWT) has been described as a method of treatment. The National Institute for Health and Clinical Excellence (NICE, UK) guidance suggests a possible benefit but with limited evidence. Materials and Methods: We retrospectively identified 71 consecutive patients who underwent ESWT for refractory GTPS over a period of 16 months. ESWT was offered to patients with refractory symptoms despite a minimum of 3 months of conservative treatment. Standardised questionnaires were used to collect data including pain scores (0-10), change in symptoms, discomfort of the procedure, and complications. Results: Fifty-nine patients (83%) were followed up. The mean time to follow up was 8 months (3 to 19). The mean age was 59 (29 to 88) with 86% females. Twothirds had improvement in their symptoms with a significant drop of 6 points in their pain score (p<0.05); however, symptoms recurred in 60% at a mean of 4 months. Most patients (60%) had mild or no discomfort from the treatment. Two patients (3.3%) could not tolerate the treatment. One complication was reported; an exacerbation of sciatica symptoms which settled spontaneously. Conclusion: This study shows an improvement in the symptoms of 67% of patients with refractory GTPS, for up to 15 months, but with frequent relapsed. Further research is required to confirm whether MRI may be useful in selecting patients for ESWT.

Analysis of therapeutic methods for treating vocal process granulomas

Conclusion: The combination of laryngeal microsurgery and local injections of botulinum toxin type A (BTA) can increase the cure rate of patients with vocal process granulomas (VPGs). Objective: To analyze the therapeutic effects of conservative treatments, microsurgical resection with suturing and microsurgery in combination with local injections of BTA for the treatment of VPGs. Methods: A retrospective analysis of 168 cases of VPG was performed. All of the patients initially received a conservative treatment. Some of the patients who did not respond to the conservative treatments were treated using microsurgical resection and microsuturing using an 8-0 absorbable filament. Other patients additionally received a four-point injection of BTA into the thyroarytenoid muscle and the arytenoid muscle on the operated side. Results: The lesions of 41.3% (71/168) of the patients who were given the conservative treatments (including acid suppression, vocal rest, and voice therapy) disappeared, and the lesions of 10.7% (18/168) of the patients were reduced. The conservative treatments were unsuccessful for 47% (79/168) of the patients. The cure rate was 78.4% (29/37) for the patients who were treated by microscope resection using a CO2 laser and microsuturing of the surrounding mucosa. Of the eight patients who experienced a recurrence, five of them had lesions that disappeared after 3 months of conservative treatment, whereas the other three patients recovered after a second operation. The cure rate of the 42 patients who were treated using microsurgery combined with local injections of BTA was 95.2% (40/42), with only 2 cases of recurrence at 2 months post-treatment.