Nonsurgical Treatment Options Research Articles

Combination Dornase and Alteplase for Intra-abdominal Drain, Abscess, and Hematoma Clearance: A Retrospective Case Series

Background: Since the advent of the MIST2 trial, the combined instillation of dornase and alteplase has become an effective nonsurgical treatment option for empyema and pleural fluid collection. Percutaneous drainage of abdominal abscesses and fluid collections, rather than open surgical treatment, also has become commonplace. The are several case reports and studies on the use of fibrinolytics to drain abdominal fluid collections but no literature reporting use of both alteplase and dornase for abdominal administration. Objective: We present a case series from an academic medical center where dornase therapy was added to fibrinolytic therapy to treat intra-abdominal fluid collections, hematoma, and abdominal drainage catheters with low output. Methods: This is an institutional review board-approved retrospective case series of 13 patients who underwent combination use of alteplase and dornase via intra-abdominal route. The primary objective was to assess for increased drain output, reduction in size of the fluid collection, and adverse events. Results: Many patients had improved drain output after dornase-alteplase therapy. One patient had significant bleeding complications. Conclusions: All patients were discharged alive from the hospital. Clinical success was difficult to define due to variable goals of therapy. Further data are needed to establish the safety and efficacy of this practice, especially compared with intra-abdominal alteplase alone. Patients in our series generally received larger doses of alteplase than in prior studies due to use of dosing modeled on the MIST2 trial. Based on the limited experience of our study, we recommend holding therapeutic anticoagulation during the administration of intra-abdominal dornase-alteplase.

Effectiveness of combined botulinum toxin and fissurectomy on chronic anal fissures - a systematic review.

Anal fissures are a debilitating benign condition, thought to be due to the hypertonicity of the internal anal sphincter resulting in localized ischaemia inhibiting healing. There are several surgical and non-surgical treatment options for chronic anal fissures. Clinical practice surveys report a trend toward sphincter-sparing options, reserving the more successful treatment of lateral sphincterotomy, with an incontinence rate up to 10%, for refractory fissures. A search of MEDLINE, Cochrane Database of Systematic Reviews and EMBASE for studies assessing sphincter-sparing treatment with botulinum toxin and fissurectomy was performed following PRISMA guidelines. Outcomes assessed included healing rate, persistence, recurrence, re-intervention and incontinence rates. Fifteen non-randomized studies assessed 978 patients managed with botulinum toxin and fissurectomy. The mean age was 40.8 years with a female predominance of 58.9%. Healing rate was reported on 14 of the 15 studies, with a healing rate of 81% (95% CI:0.67, 0.90). Persistence rate was reported as 15% (95% CI:0.07, 0.28) and a recurrence rate of 6% (95% CI: 0.01, 0.19). Re-intervention was required in 8% of patients with 55.1% requiring a repeat dose of botulinum toxin with or without fissurectomy. Incontinence appears to be transient with studies reporting a rate of 1% with median long-term follow up 23 months (range: 5-60 months). Combination fissurectomy and botulinum toxin is a safe and viable sphincter sparing treatment option, with moderate success rate and negligible complications. Randomized controlled trials are required to further strengthen the evidence for its use in chronic anal fissures.

High Versus Low-Energy Extracorporeal Shockwave Therapy for Chronic Lateral Epicondylitis: A Retrospective Study

Background: Chronic lateral epicondylitis (LE), also known as tennis elbow, affects 1–3% of the population, primarily those over 40 years old. Most cases resolve with conservative treatments, but some require more advanced interventions. Extracorporeal shockwave therapy (ESWT) has emerged as a non-surgical treatment option, utilizing either low- or high-energy levels to alleviate pain and improve function. Objective: This study aimed to compare the efficacy of low-energy versus high-energy ESWT in the treatment of chronic LE, focusing on pain relief and functional improvement. Methods: A retrospective observational study was conducted including patients treated for chronic LE between 2021 and 2024. Participants were divided into two groups: low-energy ESWT (0.10 mJ/mm2) and high-energy ESWT (0.20 mJ/mm2). Both groups received 2400 pulses at a frequency of 6 Hz once a week for three weeks. Pain and functional outcomes were measured using a visual analog scale (VAS) and the Patient-Rated Tennis Elbow Evaluation Questionnaire (PRTEE) at the baseline, three months (T1), and six months (T2) post-treatment. Results: Forty-six patients participated, with 24 in the low-energy group and 22 in the high-energy group. Baseline demographics and clinical characteristics were similar across groups. At T1 and T2, the low-energy group showed significantly greater reductions in the VAS scores (T1: 4.45 ± 0.8 vs. 3.6 ± 1.7, p = 0.04; T2: 3.2 ± 1.2 vs. 2.1 ± 1.1, p = 0.004) and PRTEE scores (T1: 34.3 ± 6.9 vs. 26.8 ± 11.9, p = 0.03; T2: 25.3 ± 6 vs. 17.6 ± 9, p = 0.005). Significant treatment–time interactions were observed for both the VAS and PRTEE scores, indicating sustained improvements in the low-energy group. Conclusions: Low-energy ESWT was more effective than high-energy ESWT in treating chronic LE, providing greater and longer-lasting pain relief and functional improvement. These findings suggest that low-energy ESWT should be preferred in clinical practice for managing this condition. Future research should focus on larger sample sizes and randomized controlled trials to confirm these results and explore the underlying mechanisms of differential efficacy between energy levels.

The application of cell products for the treatment of critical limb ischemia in patients with diabetes mellitus: a review of the literature

The number of patients with diabetes mellitus (DM) has been progressively increasing worldwide over the past decades, and many international organizations consider DM as a public health emergency of the 21st century.Critical limb ischemia (CLI) is the most severe stage of peripheral arterial disease (PAD) in DM and is characterized by a high risk of limb loss without revascularization. Traditional treatment tactics include open and endovascular revascularization surgical techniques. However, in patients not eligible for revascularization and in cases where performed surgical treatment performed has been ineffective, there are almost no therapeutic alternatives, often leading to amputations and death. As of today, one of the newest non-surgical treatment options is cell therapy. Among different cells, mesenchymal stromal cells (MSCs) are potentially one of the most prospective for use in this patient population.This article provides an overview of clinical trials using cell therapy in patients with CLI.To analyze publications, electronic databases PubMed, SCOPUS, ClinicalTrials, and ScienceDirect were searched to identify published data from clinical trials, research studies, and review articles on cell therapy for critical lower extremity ischemia. After the search, 489 results were received.As a result of systematic selection, 22 clinical trials were analyzed.According to the analyzed literature data, the use of cell products in this category of patients is effective and safe. Cell therapy can stimulate the formation of new vessels and enhances collateral circulation; it is also reported improved distal perfusion, increased pain-free walking distance, decreased amputation rates, and increased survival rates.Nevertheless, further study of the potential use of this category of drugs is needed.

Focused High-Energy Extracorporeal Shock Wave Therapy (ESWT) for Bone healing Disorders of the Forearm and the Hand

ESWT is a non-surgical treatment option but can also be used in addition to surgical treatment (stabilisation, freshening, defect filling, removal of discomforting osteosynthesis material) for the treatment of delayed bone healing (DBH) and non-union (NU). Its value as well as influencing factors on the upper extremity have not been adequately quantified so far. Sixty cases were retrospectively studied after application of focused high-energy ESWT with regard to healing rate and consolidation time. The influence of age, location, time of treatment and treatment prior to and concurrent with ESWT were analysed. In 70% of the cases, healing occurred after a median of 2.4 months (DBH) and 2.8 months (NU). The median age of healed (DBH 44 y., non-union 35 y.) and non-healed (DBH 51 y., NU 37 y.) did not differ significantly. The time between trauma/surgery and ESWT was 4.2 months for DBH in healed and 3.7 months in non-healed without a significant difference, and 27 months for NU in both healed and non-healed. Age and smoking status also had no influence. The healing rate was highest at metacarpal bone/finger/thumb (91%), followed by forearm shaft (88%), epiphysis/metaphysis of the forearm (67%), and, lastly, carpal bones (59%). After conservative pre-treatment, 55% healed, compared with 67% after more than two previous surgeries, 73% without any pre-treatment, and 75% after one previous surgery. Further analysis of surgical pre-treatment showed 85% healing after ORIF alone, 64% without previous surgery, and 57% healing after ORIF with bone grafting/debridement. Intraoperative ESWT combined with bone debridement/transplantation and ORIF resulted in 67% healing, compared with 86% in combination with ORIF alone. ESWT alone or with only minimal measures (removal of osteosynthesis material) led to 70% consolidation. ESWT is equally effective at any stage of a bone healing disorder. The principles of stability and filling of bone defects must also be taken into account when using ESWT; then ESWT alone or combined with surgery is equally effective. The negative influence of bone defects/resorption is still detectable even with ESWT. Furthermore, treatment of the scaphoid is more problematic compared with other locations. Previous surgery is not a negative factor, even with osteosynthesis material in situ.

The effect of intra-articular autologous protein solution on knee osteoarthritis symptoms.

Knee osteoarthritis (OA) is characterized by a chronic inflammatory process involving multiple cytokine pathways, leading to articular cartilage degeneration. Intra-articular therapies using pharmaceutical or autologous anti-inflammatory factors offer potential non-surgical treatment options. Autologous protein solution (APS) is one such product that uses the patient's blood to produce a concentrate of cells and anti-inflammatory cytokines. This study evaluated the effect of a specific APS intra-articular injection (nSTRIDE) on patient-reported outcome measures compared to saline in moderate knee OA. A parallel, double-blinded, placebo-controlled randomized controlled trial was conducted, where patients with unilateral moderate knee OA (Kellgren-Lawrence grade 2 or 3) received either nSTRIDE or saline (placebo) injection to their symptomatic knee. The primary outcome was the difference in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score at 12 months post-intervention. Secondary outcomes included WOMAC component scores, Knee injury and Osteoarthritis Outcome Score (KOOS), and visual analogue scale (VAS) scores at all follow-up timepoints (three, six, and 12 months). A total of 40 patients were analyzed (21 nSTRIDE; 19 saline) in the study. No significant difference was found between nSTRIDE and saline groups for WOMAC total score at 12 months (mean difference -10.4 (95% CI -24.4 to 3.6; p = 0.141). There were no significant differences in WOMAC or KOOS scores across all timepoints. VAS scores favoured the saline group for both rest and worst pain scales at 12 months post-injection (mean difference (worst) 12 months 21.5 (95% CI 6.2 to 36.8; p = 0.008); mean difference (rest) 12 months 17.8 (95% CI 2.2 to 33.4; p = 0.026)). There were no adverse events recorded in either study group. Our study demonstrates no significant differences between nSTRIDE and saline groups in KOOS and WOMAC scores over time. Notably, APS injection resulted in significantly worse pain symptoms at 12 months compared to saline injection.

Is PRP a viable nonsurgical treatment option for knee osteoarthritis?

Is PRP a viable nonsurgical treatment option for knee osteoarthritis?

Successful conservative management of advanced pyogenic sternoclavicular joint arthritis with osteomyelitis and pulmonary infiltration: a case report

BackgroundSternoclavicular joint arthritis is a rare condition that poses considerable diagnostic and therapeutic challenges, leading to severe complications and a high mortality rate. Although surgical interventions are often considered necessary for advanced cases, some reports have suggested that conservative management with antibiotic therapy can be effective in certain cases. However, to our knowledge, there are no reports of successful conservative treatment in cases exhibiting aggressive spread. This report highlights a case of advanced sternoclavicular joint arthritis with bone destruction and pulmonary infiltration, successfully treated conservatively with outpatient antibiotic therapy.Case presentationA 58-year-old Japanese male presented with a 1-month history of left-sided shoulder pain. Contrast-enhanced computed tomography showed abscess formation and clavicular bone destruction, with infiltrative shadows suggesting lung involvement. The diagnosis of sternoclavicular joint arthritis was made, and outpatient oral antibiotic therapy was initiated. The patient exhibited a marked reduction in inflammatory marker levels and symptoms, and antibiotic therapy was discontinued after 3 weeks, with no recurrence observed at a 4-month follow-up.ConclusionsThis case highlights that conservative management with antibiotics can be effective for treating advanced sternoclavicular joint arthritis, emphasizing the need for individualized management and further research into non-surgical treatment options.

Innovative therapies for hair restoration and rejuvenation: an overview

Hair loss and baldness are incredibly common conditions with a significant negative impact on a person's psychosocial functioning and quality of life. Only two drug treatments are currently available for the treatment of hair loss, but side effects render their usage limited. Substantial advancements in hair restoration and rejuvenation in aesthetic medicine have been achieved, particularly in non-surgical treatment options. Francesca Ramadan supplies an overview of some of the options most commonly offered in aesthetics clinics.

A Consensus Statement on the Administration of Systemic Bevacizumab in Patients with Recurrent Respiratory Papillomatosis.

To provide detailed guidance on the administration of systemic bevacizumab in patients with recurrent respiratory papillomatosis (RRP) based on a detailed review of the scientific literature and a consensus of experts with real-world clinical experience. A bevacizumab consensus working group (N = 10) was composed of adult and pediatric otolaryngologists, adult and pediatric oncologists, and a representative from the RRP Foundation (RRPF), all with experience administering systemic bevacizumab in patients with RRP. After extensive review of the medical literature, a modified Delphi method-based survey series was utilized to establish consensus on the following key areas: clinical and patient characteristics ideal for treatment candidacy, patient perspective in treatment decisions, treatment access, initial dosing, monitoring, guidelines for tapering and discontinuation, and reintensifying therapy. Seventy-nine statements were identified across nine critical domains, and 45 reached consensus [clinical benefits of bevacizumab (3), patient and disease characteristics for treatment consideration (7), contraindications for treatment (3), shared decision-making (incorporating the patient perspective) (5), treatment access (3), initial dosing and administration (8), monitoring (7), tapering and discontinuation (6), and reintensification (3)]. This consensus statement provides the necessary guidance for clinicians to initiate systemic administration of bevacizumab and represents a potential paradigm shift toward nonsurgical treatment options for patients with RRP. 5 Laryngoscope, 2024.

Development of an artificial intelligence–based model to predict early recurrence of neuroendocrine liver metastasis after resection

PurposeWe sought to develop an artificial intelligence (AI)–based model to predict early recurrence (ER) after curative-intent resection of neuroendocrine liver metastases (NELMs). MethodsPatients with NELM who underwent resection were identified from a multi-institutional database. ER was defined as recurrence within 12 months of surgery. Different AI-based models were developed to predict ER using 10 clinicopathologic factors. ResultsOverall, 473 patients with NELM were included. Among 284 patients with recurrence (60.0%), 118 patients (41.5%) developed an ER. An ensemble AI model demonstrated the highest area under receiver operating characteristic curves of 0.763 and 0.716 in the training and testing cohorts, respectively. Maximum diameter of the primary neuroendocrine tumor, NELM radiologic tumor burden score, and bilateral liver involvement were the factors most strongly associated with risk of NELM ER. Patients predicted to develop ER had worse 5-year recurrence-free survival and overall survival (21.4% vs 37.1% [P = .002] and 61.6% vs 90.3% [P = .03], respectively) than patients not predicted to recur. An easy-to-use tool was made available online: (https://altaf-pawlik-nelm-earlyrecurrence-calculator.streamlit.app/). ConclusionAn AI-based model demonstrated excellent discrimination to predict ER of NELM after resection. The model may help identify patients who can benefit the most from curative-intent resection, risk stratify patients according to prognosis, as well as guide tailored surveillance and treatment decisions including consideration of nonsurgical treatment options.

Use of a Penrose Drain for Decompression of a Large Periapical Lesion: A Case Report With 4.5-Year Follow-up

Managing large cyst-like periapical lesions poses significant challenges, especially when nonsurgical treatment or retreatment options are ineffective. Despite its efficacy, decompression remains an underutilized minimally invasive alternative in modern dentistry. This case report describes the use of a Penrose drain for decompression following aspiration and irrigation to manage a large periapical lesion associated with a 56-year-old man's maxillary lateral incisor. The lesion had caused thinning and perforation of the facial and palatal cortical plates, as well as the inferior border of the nasal fossa. Cone-beam computed tomography was used to evaluate the lesion preoperatively and to assess the healing progress postoperatively. Complete 3-dimensional healing was observed after a subsequent root-end surgery performed 3.5 years post-decompression. This report suggests that decompression using a Penrose drain in combination with aspiration and irrigation could be a simple but effective modality for managing large cyst-like periapical lesions when nonsurgical endodontics are attempted and deemed ineffective.

Surgical Management of Massive Irreparable Cuff Tears/Management of Rotator Cuff Disease: Interpositional Graft for Irreparable Posterosuperior Rotator Cuff Tears.

Increasingly, massive irreparable rotator cuff tears present a treatment challenge due to their high re-tear rates. The reparability of such tears depends on factors like tear size, the number of involved tendons, tendon retraction extent, muscular atrophy, fatty infiltration, and the presence or absence of arthritis. There are non-surgical and several surgical treatment options described each with their specific indications, contraindications, pros, and cons. Bridging reconstruction restores the superior rotator cuff tissue and arrests humeral head superior migration. The purpose of his review is to explore the existing literature on interpositional graft mechanics, indications, surgical technique, and clinical outcomes. It aims to understand how these parameters can facilitate the incorporation of bridging reconstruction using interpositional grafts into a surgeon's practice for managing massive irreparable rotator cuff tears. Interpositional grafts for irreparable massive rotator cuff tears can either be auto-, allo-, xenografts, or synthetic material and are best suited for patients who are relatively younger, no glenohumeral arthritis, and minimal to no fatty infiltration and muscle atrophy. Short to medium term outcome studies available report good functional, clinical, and radiological improvements with bridging reconstruction utilizing acellular dermal matrix allograft. Interpositional grafts for management of irreparable posterosuperior cuff tears provides improved clinical and radiological outcomes with minimal complications and thus a viable and valuable surgical technique for a shoulder surgeon's armamentarium.

Treatment of Class III Malocclusion with Open Bite and Macroglossia Using an Anterior Loop

General Background: Class III malocclusion is a prevalent dental anomaly characterized by the anterior positioning of the mandible relative to the maxilla, posing functional and aesthetic challenges. Specific Background: This condition may present with additional complexities such as dental crowding, open bite, and macroglossia, complicating the orthodontic treatment approach. Knowledge Gap: While conventional treatment modalities include orthognathic surgery and growth modification, there is limited documentation on the efficacy of orthodontic camouflage in non-surgical settings, particularly in adults with completed growth. Aims: This study aims to evaluate the effectiveness of orthodontic camouflage using anterior stainless steel loops in managing dentoskeletal Class III malocclusion accompanied by anterior open bite and macroglossia, without premolar extraction. Results: Over a 7-month treatment period, significant corrections in overjet, overbite, and molar relationship were achieved, demonstrating the potential of this approach as a non-surgical alternative. Novelty: This research introduces a modified technique involving stainless steel wire with specific loop placements, contributing to the orthodontic management strategies for complex Class III cases. Implications: The findings support the broader application of camouflage techniques in orthodontic practice, offering a viable option for patients opting out of surgery and highlight the need for further studies to optimize and validate such approaches.Highlights: Efficiency of Camouflage: Shows how orthodontic camouflage can effectively treat complex Class III malocclusion without surgery. Novel Technique: Introduces a new method using stainless steel loops in wires to enhance treatment outcomes. Clinical Implications: Expands non-surgical treatment options in orthodontics, offering viable alternatives to surgery. Keywords: Class III Malocclusion, Orthodontic Camouflage, Open Bite, Macroglossia

Long-term follow-up of levonorgestrel intrauterine device for atypical hyperplasia and early endometrial cancer reveals relapse characterized by immune exhaustion.

Nonsurgical treatment options are increasingly needed for endometrial atypical hyperplasia (AH) and endometrioid endometrial cancer (EEC). Despite promising initial response rates, prospective long-term data and determinants for relapse are limited. Follow-up data from patients in our prospective phase II trial of LIUD for AH/G1EEC were collected from medical records. Spatial transcriptomics (Nanostring GeoMX digital spatial profiling) with in silico cell type deconvolution and pathway analyses were employed on longitudinal biopsy samples from five patients across pre-treatment, on-treatment, and relapse. Of 43 participants exhibiting initial response to LIUD, 41 had follow-up data. Sixteen (39%) experienced relapse. Clinical factors associated with shorter response duration included younger age, initial diagnosis of G1EEC, lack of response at six months, premenopausal status, and Hispanic ethnicity (p<0.05), but only six-month response status remained a significant predictor in a multivariate model (p=0.023). LIUD increased abundance of NK cells (DMCP-counter score=46.13, FDR=0.004) and cytotoxic lymphocytes (DMCP-counter score=277.67, FDR=0.004), as well as lymphocyte cytotoxicity markers PRF1 (log2FC=1.62, FDR=0.025) and GZMA (log2FC=2.47, FDR=0.008). NK cells were reduced at relapse (DMCP-counter score=-55.96, FDR=0.02). Immune-related pathways (IFNα-response and TGFβ-signaling) were enriched at relapse (FDR<0.05). IDO1 expression, reflecting immune exhaustion, was upregulated at relapse (FDR<0.05). Upfront resistance and relapse after initial response to LIUD for AH/G1EEC impacts nearly half of patients, remaining a major hurdle for non-surgical treatment of AH/G1EEC. Molecular studies evaluating longitudinal biopsies from a small cohort implicate immune mechanisms at relapse, including reversal of progestin-related immunomodulation and increased immune exhaustion.

Prevention and treatment of microstomia.

The mouth, located in the lower third of the face, is a uniquely visible structure. It serves as a vital organ both aesthetically and functionally, playing a key role in speech, expression, and fundamental oral functions. Consequently, any alterations or defects in its shape, due to various causes, can lead to aesthetic and functional deficiencies. These issues may also result in challenges with social interactions and a decrease in confidence. In cases of microstomia, various surgical approaches are proposed based on the location, extent, shape, and cause of the defect, leading to numerous case reports. Plastic surgeons are proficient in oral reconstruction; however, cases of microstomia are relatively rare, which reduces their familiarity and interest in these cases. Additionally, preferences for oral size and shape vary according to factors such as geographical region and ethnicity, further complicating the functional definition of microstomia. Therefore, both subjective patient and physician judgments play crucial roles in the diagnosis and treatment of microstomia, as these may vary depending on individual and societal aspects. This review aims to classify the various causes and definitions of microstomia, as well as its non-surgical and surgical treatment options, with the goal of the treatment of this condition.

LGG-21. IMMUNE MICROENVIRONMENT PROFILING OF BRAF-FUSION PILOCYTIC ASTROCYTOMA: DIRECTIONAL PRIORITIZATION OF IMMUNOTHERAPEUTIC TARGETS

Abstract BACKGROUND The immune microenvironment of pediatric gliomas is relatively understudied despite being a leading cause of childhood mortality. Pilocytic astrocytomas (PA) are the most common pediatric glioma and surgical resection is often curative. However, PAs are not always amenable to surgery and can have significant long-term morbidity and mortality. The ten-year progression-free survival for PA patients with significant residual tumor is less than 50% and other non-surgical treatment options are frequently necessary. METHODS To identify PA patients that may be responsive to immune checkpoint inhibitors and to guide prioritization of available immunotherapeutic treatments, orthogonal immune profiling strategies were used to identify patients that may benefit from the next generation of immune therapeutics. Because the KIAA1549-BRAF fusion is expressed in 70% of PA, we prospectively collected patients to comprehensively characterize the unique immune biology of these tumors using nanostring profiling, scRNASeq, and SeqIF™ multiplex staining. RESULTS The tumor microenvironment of BRAF-fusion PA was notable for antigen presentation and the interaction of CD11c+ cells with T cells through Lck+ immunological synapses. PA CD11c+CD206+ dendritic cells localized to vessel walls and were positive for TIM3 expression, an immune checkpoint marker. A unique highly activated microglia subcluster was identified that morphologically resembled T cells expressing TNF and TIM3. Our results are consistent with others that suggest potential benefit in targeting tumors with elevated MAPK activity. Finally, the expression of other immune checkpoints such as Lag-3, PD-1, and TIGIT are minimally co-expressed, suggesting that T cells are not in a state of exhaustion, as seen in adult high-grade gliomas. CONCLUSIONS Analysis of BRAF-fusion PA identified a unique highly activated P2RY12+ microglia population dispersed throughout the tumor microenvironment, active antigen presentation between a CD11c+ antigen presenting cells and T cells, and a unique therapeutic opportunity for targeting TIM3.

Inguinal lymphangioma in an adult patient mimicking an irreducible inguinal hernia: A case report

IntroductionLymphangiomas are rare benign vascular malformations of the lymphatic system. They are usually located in the head, neck, and axilla and are typically present during the first two years of life. A few cases of inguinal lymphangioma have been reported in adults. Case presentationWe report a 35-year-old male who presented with left groin swelling for a one-year duration associated with on and off pain. On examination, he had soft, irreducible left inguinal swelling with positive cough impulse and no tenderness on palpation. Ultrasound (US) and magnetic resonance imaging (MRI) were done for him, showing a well-defined lobulated cystic lesion located between subcutaneous and deep fascia measuring around 6.5 × 4.2 × 8.1 cm with multiple internal septations. The lesion shows Low signal intensity in the T1 weighted image and high signal intensity in the T2 weighted image. 97 % alcohol was injected under US guidance and aspirated after 30 min. The swelling significantly decreased in size clinically and radiologically during the follow-up. Clinical discussionLymphangioma rarely occurs in the inguinal region, presenting a diagnostic challenge as it mimics various inguinal conditions. Differential diagnoses include inguinal hernia, hydrocele of the cord, lymphadenopathy, or hematoma. Imaging is used to determine the size, invasion, relation to surrounding structures, and extension to the abdominal cavity. MRI is the diagnostic modality of choice in non-emergency settings. Complete surgical excision is the gold standard for the management with the lowest risk of recurrence. Alternative non-surgical treatment options have been used successfully in poor surgical candidates. Different sclerosing agents have been used with low complications and rates of recurrence. Ethanol is a widely available sclerosing agent, and it was used with no recurrence or side effects during the follow-up period. ConclusionSurgeons should have a high index of suspicion when investigating any inguinal mass, considering such a rare presentation as part of the differential. Sclerotherapy is an effective treatment for lymphangioma and should be considered as an alternative modality in non-surgical candidates.

Bony Bankart Lesion: Diagnosis, Management, and Outcomes.

» Bony Bankart lesions are fractures of the anteroinferior glenoid rim, commonly associated with a traumatic anterior shoulder dislocation, and are diagnosed through radiological imaging and physical examination. Young male athletes playing contact sports are at highest risk of these injuries. Early diagnosis and treatment are crucial because, if left untreated, recurrent anterior shoulder instability and glenoid bone loss can occur. Both nonsurgical and surgical treatment options are available depending on the size of the lesion, with arthroscopic repair being the most common treatment method. After repair, patients typically have favorable outcomes with low rates of recurrent instability. This review aims to discuss the etiology, diagnosis, and treatment of bony Bankart lesions.» Bony Bankart lesions are fractures of the anteroinferior glenoid rim and occur in up to 22% of first-time anterior shoulder dislocations.» Young men involved in contact sports or combat training are at the highest risk of sustaining bony Bankart lesions.» Diagnosis and treatment of bony Bankart lesions are essential to prevent long-term shoulder instability.» Bony Bankart lesions can be treated either nonoperatively or operatively (arthroscopic vs open repair), with the size of the glenoid defect being the primary determinant of treatment.

Mind the gap: paramedian approach for coccygectomy

Background ContextCoccydynia is pain in the coccyx that typically occurs idiopathically or from trauma. Most forms are self-limiting. However, if symptoms persist, nonsurgical treatment options can include offloading, NSAIDs, physical therapy, and steroid injections. If all treatment options fail, a growing body of evidence supports a coccygectomy for symptomatic relief. The standard approach for a coccygectomy involves a midline incision cephalad to the anus along the gluteal cleft. Historically, this method has had high rates of infection. PurposeTo improve healing and decrease infection rate, we propose the paramedian approach to a coccygectomy. This approach has the benefit of distancing the surgical site from the anus, diminishing the crevice effect of the incision, and increasing the dermal and subdermal thickness for improved surgical closure. Study Design/SettingWe present a case series study of 41 patients who underwent the paramedian approach coccygectomy using a 4 to 6 cm incision, approximately 0.5 to 1.5 cm lateral to the midline, for coccyx removal. These patients were evaluated postoperatively to determine infection rate and various outcome measures. Patient SampleForty-one patients suffering from refractory coccydynia had a coccygectomy via the paramedian approach between 2011 and 2022 by the senior author. Outcome MeasuresOutcome measures included self-reported measures (Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) pain scale and satisfaction with procedure), physiologic measures (presence of infection and treatment provided) and functional measures (return to vocation/avocation). MethodsData was compiled and transferred to Microsoft Excel and analyzed. Two-tailed T-tests were used to compare the patient improvement in VAS and ODI as appropriate for statistical analysis. ResultsThe patients' average age was 45.8 years. Patients' average body mass index was 27.9, with 71% of patients overweight or obese. A total of 68% of patients were female. Trauma was the most common precipitating factor (75.6%). Five patients presented with postoperative complications (12.1%), one requiring an incision and drainage, and four others were treated with antibiotics for wound erythema. Postoperative evaluations showed continual improvement, with the most significant improvement reported greater than 1-year postoperatively. The Visual Analogue Scale for pain dropped from 7.5 to 2.3 (p<.001), and the Oswestry Disability Index improved from 30.1 to 9.6 (p<.001). A total of 86.7% of patients reported either a good or excellent result. ConclusionCoccygectomies via the midline approach have a variable infection rate, likely due to proximity of the incision to the anus and due to the crevice effect of the gluteal cleft in terms of aeration. These contributing factors are overcome in the paramedian approach, making it an effective option for treating refractory coccydynia that is nonresponsive to conservative management.