Nonoperative Treatment Research Articles

Medial patellofemoral ligament injury. Location-based rate of recurrent patellar dislocation after non-operative treatment

ObjectivesThe role of the medial patellofemoral ligament (MPFL) as a patellofemoral joint stabilizing structure is undisputable. After traumatic patellar dislocation, MPFL injury, together with bone edema in the medial patellar facet and lateral femoral condyle, is a pathognomonic finding in magnetic resonance imaging (MRI). MPFL injury in the femoral insertion has been reported to most likely predict recurrent dislocations. The objective of this study was to detect if any MPFL injury location predicts the earliest onset of the patellar re-dislocation. MethodsIn total, 64 eligible patients with a first-time traumatic patellar dislocation were recruited to the trial. The diagnosis was confirmed within 3 weeks with 3T magnetic resonance imaging. The location of the MPFL injury in MRI was localized at the patellar insertion, midsubstance area, femoral insertion, or a combination of these. During the three-year follow-up period, patellar re-dislocations, range of motion, quadriceps muscle atrophy, and daily symptoms were determined. All the patients were treated non-operatively. ResultsOut of 64 patients, 33 (51.6%) had at least one episode of patellar re-dislocation. Re-dislocations occurred in 8 out of 25 (32.0%) patients with the main injury at the femoral insertion, 5 out of 15 (33.3%) patients with the main injury at the midsubstance area, and 10 out of 24 (41.7%) patients with the main injury at the patellar insertion during the 36 months follow-up (p ​= ​0.758). According to Kaplan–Meier analysis, the location of MPFL injury did not have any statistically significant effect on the timing of re-dislocations. At 36 months, survival of patients with MPFL injury at the patellar insertion was 70.8%, which was not statistically significantly different than the survival in patients with injury at the femoral insertion (88.0%) or at the midsubstance area (93.3%). No differences between single and multiple MPFL injuries were found. At 4 weeks, the range of motion was more restricted in patients with MPFL injury at the femoral insertion (93.4° vs. 108.0° for injury at the midsubstance area and 107.7° at the patellar insertion). ConclusionThe location of MPFL injury did not have any statistically significant effect on timing or the rate of re-dislocations. The MPFL injury at the femoral insertion predicts decreased range of motion (ROM) of the knee and increased quadriceps muscle atrophy during the first three months after sustaining injury. Level of evidenceLevel III.

Intramedullary nailing of proximal humerus fractures does not achieve superior functional results to non-operative treatment in the long term.

Non-operative treatment (NOT) of proximal humerus fractures (PHF) has regained significance due to recent evidence. Additionally, positive outcomes of plate osteosynthesis and fracture arthroplasty prompt a reassessment of the role of intramedullary nailing (IMN). While favorable short and medium-term results have been documented following IMN, little is known regarding functional outcomes and quality of life in the long-term. Data from 180 patients with dislocated PHF of Neer types III, IV and V, treated at our level-I trauma center between 2004 and 2014 using IMN or NOT therapy, were scanned. Patients were re-evaluated after a minimum of 5 years to assess functional outcomes (age- and sex-adapted Constant Score, QuickDASH), quality of life (SF12), and complications or reoperations. Out of the initially identified 180 patients, 51 were unavailable for follow-up (FU) and 71 had deceased during the FU period. Functional outcomes and quality of life was, therefore, assessed in 58 patients (30 IMN, 28 NOT) with an average age at injury of 68 years after a mean FU time of 10.3 ± 3.4 years. Epidemiological patient characteristics did not exhibit significant differences between the two groups (p > .05). The functional outcome assessed by age- and sex-adapted Constant Score (NOT: 74 ± 28; IMN: 68 ± 24; p = .438), QuickDASH (NOT: 25 ± 27; IMN: 31 ± 23; p = .374) or quality of life using the SF12 (p > .05) revealed no significant disparities in long-term outcomes between the treatment groups. 10 of 30 patients in the IMN group underwent surgical revision to address complications, exceeding mere implant removal. Conversely, no patient in the NOT group underwent a revision surgery during the FU period. In the long-term, functional and quality of life-related outcomes of IMN did not diverge significantly from those of NOT, while causing a higher incidence of follow-up interventions.

The Hematoma Block versus Hematoma Plus Wrist Nerve Block in the Reduction of Distal Radius Fractures

Abstract Background Distal radius fractures are extremely common. Most of them can be treated conservatively, but there are still many controversies about this nonoperative treatment. The purpose of this study was to assess whether the pain experienced during distal radius fracture reduction using the hematoma block plus a nerve block at the wrist is less than the perceived pain using an isolated hematoma block and whether the success of the closed reduction remains at least the same. Methods A total of 192 patients were included in a comparative study to assess whether the pain experienced during wrist fracture reduction using the hematoma block plus a nerve block at the wrist was less than using an isolated hematoma block and whether they were equally effective. Results The mean Visual Analog Scale (VAS) for pain at the wrist was 4.6 in the hematoma plus nerve block and 5.1 in the isolated hematoma block. The score at the fingers was 5.2 in the hematoma plus nerve block and 7.3 in the hematoma block. The success of the procedure was the same among groups. Conclusions The hematoma plus nerve block is more effective than the isolated hematoma block in reducing the pain during wrist fracture reduction, especially for fingers pain. The mean VAS was far from ideal and further focused research can be very useful because of the great clinical impact it can have. Level of Evidence Therapeutic study. Prospective cohort study—Level II.

Contemporary Practice Patterns in the Treatment of Cervical Stenosis and Central Cord Syndrome: A Survey of the Cervical Spine Research Society.

Cross-sectional study. To evaluate for areas of consensus and divergence of opinion within the spine community regarding the management of cervical spondylotic conditions and acute traumatic central cord syndrome (ATCCS) and the influence of the patient's age, disease severity, and myelomalacia. There is ongoing disagreement regarding the indications for, and urgency of, operative intervention in patients with mild degenerative myelopathy, moderate to severe radiculopathy, isolated axial symptomatology with evidence of spinal cord compression, and ATCCS without myelomalacia. A survey request was sent to 330 attendees of the Cervical Spine Research Society (CSRS) 2021 Annual Meeting to assess practice patterns regarding the treatment of cervical stenosis, myelopathy, radiculopathy, and ATCCS in 16 unique clinical vignettes with associated MRIs. Operative versus nonoperative treatment consensus was defined by a management option selected by >80% of survey participants. Overall, 116 meeting attendees completed the survey. Consensus supported nonoperative management for elderly patients with axial neck pain and adults with axial neck pain without myelomalacia. Operative management was indicated for adult patients with mild myelopathy and myelomalacia, adult patients with severe radiculopathy, elderly patients with severe radiculopathy and myelomalacia, and elderly ATCCS patients with pre-existing myelopathic symptoms. Treatment discrepancy in favor of nonoperative management was found for adult patients with isolated axial symptomatology and myelomalacia. Treatment discrepancy favored operative management for elderly patients with mild myelopathy, adult patients with mild myelopathy without myelomalacia, elderly patients with severe radiculopathy without myelomalacia, and elderly ATCCS patients without preceding symptoms. Although there is uncertainty regarding the treatment of mild myelopathy, operative intervention was favored for nonelderly patients with evidence of myelomalacia or radiculopathy and for elderly patients with ATCCS, especially if pre-injury myelopathic symptoms were present. Level V.

Incidence of Cancer and Cardiovascular Disease After Bariatric Surgery in Older Patients

Bariatric surgery is associated with decreased risk of obesity-related cancer and cardiovascular disease but is typically reserved for patients younger than 60 years. Whether these associations hold for patients who undergo surgery at older ages is uncertain. To determine whether bariatric surgery is associated with a decreased risk of obesity-related cancer and cardiovascular disease in patients who underwent surgery at age 60 years or older. Population-based cohort study of patients from Denmark, Finland, and Sweden who underwent bariatric surgery at age 60 years or older without previous malignant neoplasm or cardiovascular disease between 1989 and 2019. Each patient who underwent surgery was exactly matched to 5 patients with nonoperative treatment for obesity of the same country, sex, and age at the date of surgery. Data were analyzed in December 2023. Receiving treatment for obesity, including bariatric surgery and nonoperative treatments. The main outcome was obesity-related cancer, defined as a composite outcome of breast, endometrial, esophageal, colorectal, and kidney cancer, identified from the national cancer registries. The secondary outcome was cardiovascular disease, defined as a composite outcome of myocardial infarction, ischemic stroke, and cerebral hemorrhage, identified from the patient registries. Multivariable Cox regression provided hazard ratios (HR) with 95% CIs adjusted for diabetes, hypertension, peripheral vascular disease, chronic obstructive pulmonary disease, kidney disease, and frailty. In total, 15 300 patients (median [IQR] age, 63 [61-65] years; 10 152 female patients [66.4%]) were included, of which 2550 (16.7%) had bariatric surgery at age 60 or older and 12 750 (83.3%) had nonoperative treatment. During a median (IQR) of 5.8 (2.8-8.5) person-years of follow-up, 658 (4.3%) developed obesity-related cancer and 1436 (9.4%) developed cardiovascular disease. The risk of obesity-related cancer (HR, 0.81; 95% CI, 0.64-1.03) and cardiovascular disease (HR, 0.86; 95% CI, 0.74-1.01) were similar among who underwent surgery and those who did not. Gastric bypass (1930 patients) was associated with a decreased risk of obesity-related cancer (71 patients [3.7%]; HR, 0.74; 95% CI, 0.56-0.97) and cardiovascular disease (159 patients [8.2%]; HR, 0.82; 95% CI, 0.69-0.99) compared with matched controls (9650 patients; obesity-related cancer: 442 patients [4.6%]; cardiovascular disease: 859 patients [8.9%]). This cohort study found that bariatric surgery in older patients is not associated with lower rates of obesity-related cancer and cardiovascular events, but there was evidence that gastric bypass may be associated with lower risk of both outcomes.

Recalcitrant Lateral Epicondylitis: A Systematic Review on Current Nonoperative and Operative Treatment Modalities.

Lateral epicondylitis is a common cause of elbow pain that is generally self-limiting. For patients who have persistent symptoms refractory to conservative treatment, there is still no clear consensus on the most favorable treatment modality. The purpose of this systematic review was to synthesize the available literature regarding both nonoperative and operative treatment modalities for recalcitrant lateral epicondylitis (RLE) to provide insight into the efficacy of treatment options. A systematic review was performed in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, where the PubMed, MEDLINE/Ovid, CINAHL, Cochrane, and Scopus databases were queried to identify studies evaluating treatment options for RLE. A total of 27 studies with 1,958 patients were included. Of the reviewed studies, there were a wide variety of treatments including platelet-rich plasma injections, percutaneous tenotomies, and various arthroscopic and open procedures. There are a wide variety of treatment modalities available for RLE that have promising efficacy in the short, medium, and long terms. A comprehensive approach combining evidence-based and patient-centered care is critical for effective management of refractory symptoms. Level IV. See Instructions for Authors for a complete description of levels of evidence.

Impact of size and fragmentation of the anteroinferior glenoid rim on clinical and functional outcomes of non-operatively treated Bony Bankart lesions in middle-aged population

IntroductionThe optimal treatment approach for Bony Bankart remains a subject of considerable debate among shoulder surgeons. Existing literature highlights low recurrence rates and high patient satisfaction with nonoperative treatment, particularly in the middle-aged population. This study aimed to evaluate the recurrence rate of dislocation, as well as the clinical and functional outcomes in middle-aged individuals treated nonoperatively following an acute bony Bankart fracture. Additionally, the impact of glenoid rim size and fragmentation on the treatment outcome was investigated.Material and methodsA prospective analysis was conducted on 20 patients aged over 50 with nonoperatively treated bony Bankart fractures, ensuring a minimum follow-up of 24 months. The study population was categorized based on fragment size (small and medium) according to Kim classification and glenoid rim fragmentation (type 1b and 1c) according to Scheibel classification. Data including UCLA score, Rowe score, recurrence rate, clinical instability, and range of motion (ROM) were collected and analyzed.ResultsThe average UCLA and Rowe scores were 32.15 ± 2.85 and 93.85 ± 2.19, respectively, with no instances of dislocation recurrence. The affected shoulder exhibited no significant reductions in ROM compared to the contralateral side, except for a loss of external rotation (ER) (13.08° ± 7.51; p = 0.005). No differences were observed based on fragment size, although patients with multifragmented glenoid rims showed a greater loss of ER compared to those with a solitary fragment, albeit not reaching statistical significance.ConclusionNonoperative treatment appears to be a viable and effective option for middle-aged individuals with bony Bankart fractures, resulting in favorable functional outcomes and a low risk of recurrence. Additionally, a notable loss of external rotation was observed in fractures with glenoid rim fragmentation.Level of evidenceIV.

Effective Treatments for Abductor Vocal Cord Paralysis: A Comprehensive Review.

Abductor vocal cord paralysis (AVCP) is a disabling disorder that affects the voice and the quality of life of a patient, and hence, there is importance in providing a detailed knowledge of its aetiology and management. In this review article, we offer an implicational definition of AVCP and a discussion of its background, viewed as potentially affecting voice production and health. Finally, we explore modalities of diagnosis by medical history and physical examination, visualization techniques like laryngoscopy and stroboscopy, and radiographic imaging such as computed tomography (CT) and magnetic resonance imaging (MRI) scans. The article reviews and categorizes approaches into operative and non-operative treatments, including injection laryngoplasty, voice therapy, botulinum toxin injections, and the management of Reinke's edema. Surgical approaches, like arytenoid adduction, cordotomy, and posterior cordotomy, are also scrutinized taking their indication, efficacy, and complication profile into consideration. Learning about the advantages and drawbacks of the following experimental yet promising directions like nerve-muscle pedicle implantation, nerve reinnervation, and engineering of tissues is therefore highly necessitated. In conclusion, the review details the measures that have shown to be useful in the treatment process and their impact on the future practice of clinical work, calling for a more clarified structure of the organization of diagnostic, therapeutic, and rehabilitative activities. Future research directions are outlined based on the gaps which include the development of new treatment approaches, the evaluation of treatment for long-term effects, and the need for interdisciplinary cooperation in the medical field for the benefit of the patients.

Nonoperative Management of Trapeziometacarpal Joint Arthritis: A Systematic Review of the Clinical Trials.

This systematic review evaluates nonoperative treatments for trapeziometacarpal joint osteoarthritis (TMJO), a common degenerative condition in postmenopausal females causing pain, reduced mobility, and diminished grip strength.Following PRISMA guidelines, a search was conducted across PubMed, Cochrane, Embase, and MEDLINEfor randomized controlled trials (RCTs) assessing pain outcomes with nonoperative interventions over at least a six-month follow-up, using the visual analog scale (VAS) for pain measurement. Eleven RCTs yielded moderate-quality evidence for the following: (1) corticosteroid (CSI) and hyaluronic acid (HA) injections exhibit comparable mean delta pain scores after six months, with CSI offering early relief at two to three weeks. After 12 months, CSI led to a continued decrease in pain, with a mean delta pain score of 1.0 (p<0.05), contrasting with hyaluronic acid (HA) injections, which presented a modest though nonsignificant improvement, demonstrating a mean delta pain score of 0.5 (p=0.16). (2) Relatively novel therapies for TMJO, such as platelet-rich plasma (PRP) and dextrose, appear to surpass CSI in long-term effectiveness, with dextrose showing a mean delta pain score of 3.8 (p<0.001) at six months and PRP achieving a mean delta pain score of 5.5 (p=0.005) at 12 months. (3) Various hand therapies, notably standard hand exercises and extracorporeal shockwave therapy (ESWT), demonstrated significant pain reduction, with the former achieving a mean delta pain score of 1.5 (p=0.019) and the latter a score of 4.2 (p<0.001). (4) The use of orthoses substantially decreases pain levels, demonstrating a mean delta pain score reduction of 2.6 at a 180-day follow-up (p=0.023) and 2.2 at a 12-month follow-up (p=0.002). In conclusion, nonoperative treatments for TMJO, including intra-articular injections, hand therapy, and orthoses, provide significant pain relief at a minimum of six months follow-up. The synergistic effect of combined nonoperative management, as well as the effect size of each, is unknown.

Severe Thoracic Trauma Indications and Contraindications for Non-operative and Operative Treatment Strategies

Severe thoracic trauma can occur as a penetrating or blunt mono-injury or as part of a polytrauma. Almost half of all severely injured patients documented in the TraumaRegister DGU were diagnosed with severe chest trauma, defined according to the Abbreviated Injury Scale (AIS) as ≥3. In our own collective, the proportion was even higher with 60%. Emergency surgical treatment with a thoracotomy within the Trauma Resuscitation Unit or within the first hour of admission is an extremely rare intervention in Germany, accounting for 0.9% of severe thoracic injuries. The management of complex polytraumas and extensive pathophysiological reactions to the trauma, as well as knowledge about the development of secondary damage have led to the conclusion that minimally invasive procedures such as video-assisted thoracoscopy (VATS) or inserting a chest drain can resolve most severe thoracic injuries. At <4%, penetrating injuries to the thorax are a rarity. Among blunt thoracic injuries, >6% show an unstable thoracic wall that requires surgical reconstruction. The demographic development in Germany leads to a shift in injury pattern. Low-energy trauma results have lower incidence than higher-grade chest wall injuries with penetrating rib fractures in the pleura, lungs, peri-/myocardium and diaphragm. Sometimes this results in instability of the chest wall with severe restriction of respiratory mechanics, which leads to fulminant pneumonia and even ARDS (Acute Respiratory Distress Syndrome). With this background, surgical chest wall reconstruction has become increasingly important over the past decade. Together with the underlying strong evidence, the assessment of the extend and severity of the trauma and the degree of respiratory impairment are the basis for a structured decision on a non-surgical or surgical-reconstructive strategy, as well as the timing, type and extent of surgery. Early surgery within 72 hours can reduce morbidity (pneumonia rate, duration of intensive care and ventilation) and mortality. In the following article, evidence-based algorithms for surgical and non-operative strategies are discussed in the context on the management of severe thoracic injuries. Thus, a selective literature search was carried out for the leading publications on indications, treatment strategy and therapy recommendations for severe thoracic injury, chest wall reconstruction.

Four-Year Treatment Effect of Custom-Made Foot Orthosis on Pediatric Symptomatic Accessory Navicular Bone Combined with Flexible Flatfoot.

Congenital accessory navicular bone (ANB) is a common variant in the foot and is prone to cause several clinical symptoms. Wearing custom-made foot orthosis is considered a desirable option; however, there is limited evidence of its effectiveness. This study aims to report the mid-term effect of foot orthosis for symptomatic pediatric ANBs. School-age children with symptomatic ANBs combined with flexible flatfoot in the authors' institute were recruited and got custom-made foot orthosis treatment. They were followed up over 4years. The general characteristics of these children were collected before treatment, including age, gender, and body mass index (BMI). The indicators of foot symptoms, including frequency and location of pain, visual analogue scale (VAS), arch index (AI), and hind foot valgus angle (HVA), were measured during pretreatment and at the last follow-up. Twenty-seven children were recruited for this study. After 4years of custom-made foot orthosis treatment, significant improvements showed in pain frequency, VAS, AI, and HVA (P < 0.001). Type II ANBs showed a higher pain index pretreatment (P < 0.001) and reduced after treatment (P < 0.001). Mid-term effect of custom-made foot orthosis is inspiring in clinical symptoms of pediatric congenital ANBs combined with flexible flatfoot and may be an optional nonoperative treatment. The online version contains supplementary material available at 10.1007/s43465-024-01210-7.

Outcomes Following Operative Vs. Non-Operative Treatment of Completely Displaced Midshaft Clavicle Fractures in Adolescent Baseball Players and Other Overhead Athletes

Outcomes Following Operative Vs. Non-Operative Treatment of Completely Displaced Midshaft Clavicle Fractures in Adolescent Baseball Players and Other Overhead Athletes

Fresh Osteochondral Allograft Transplantation of the Capitellum for the Treatment of Osteochondritis Dissecans

Background: Osteochondritis dissecans (OCD) of the humeral capitellum is a rare and challenging condition to treat. Several surgical options exist, but in the last few years, the pendulum has swung from debridement and microfracture to restoration of the articular surface. Osteochondral autografts from the rib and knee have been described, but donor-site morbidity is a concern. Purpose: To expand the results of fresh osteochondral allograft transplantation (FOCAT) in a previously published report with inclusion of additional patients and a longer follow-up period. Study Design: Case series; Level of evidence, 4. Methods: After institutional review board approval, the charts of patients who underwent FOCAT for OCD of the capitellum between 2006 and 2022 by a single surgeon were reviewed. The majority of cases (94%) had unstable lesions (Minami grades 2 and 3). A trial of nonoperative treatment had failed in all. All patients underwent diagnostic arthroscopy, followed by a mini-open, ligament-sparing approach with grafting using commercially available guides and instruments. Results: A total of 35 patients were identified, of whom 25 were male. The mean age was 16 ± 3.9 years (range, 11-32 years). There were 24 baseball players (19 pitchers and 5 position players), 5 gymnasts, 3 cheerleaders/tumblers, 1 tennis player, 1 student (who did not participate in athletics), and 1 patient with avascular necrosis from chemotherapy. Eighteen patients had a mean flexion contracture of 14.1°± 11.9°. A single osteochondral allograft plug was used in 23 patients (mean diameter, 11.3 ± 2.8 mm), and 12 patients required 2 plugs (Mastercard technique). The mean follow-up was 92.6 ± 54.5 months (range, 24-204 months). There was significant improvement in Oxford (from 25.5 ± 4.9 to 46.7 ± 3.5; P < .00001) and visual analog scale for pain (from 7.5 ± 2 to 0.3 ± 1.0; P < .0001) scores. The mean Single Assessment Numeric Evaluation score at the time of follow-up was 90.6 ± 10.8 (range, 60-100). In overhead athletes, there was significant improvement in the Kerlan-Jobe Orthopaedic Clinic score (from 40.8 ± 11.8 to 90.6 ± 10.8; P < .00001). A postoperative magnetic resonance imaging scan was obtained in 16 (46%) patients at a mean of 32.6 months. In all cases, the graft was incorporated. All overhead athletes were able to return to their sport and perform at the same level or higher for >2 years. Two elbows required a subsequent arthroscopy for loose-body removal; otherwise, there were no other complications. Conclusion: FOCAT is an excellent option for treating OCD lesions of the humeral capitellum. Excellent outcomes and high return-to-sport rates were observed, with midterm follow-up showing no graft failures. FOCAT eliminates donor-site morbidity.

Operative Versus Nonoperative Treatment of Displaced Proximal Humerus Fractures in Adolescents: Results of a Prospective Multicenter Study

Operative Versus Nonoperative Treatment of Displaced Proximal Humerus Fractures in Adolescents: Results of a Prospective Multicenter Study

Effect of Extracorporeal Shock Wave Therapy in Conjunction with Kinetic Chain Based Exercises on Pain, Kinesiophobia, and Functional Outcome in Chronic Subacromial Pain Syndrome Participants -A Case Series

Background and Objectives: Chronic Subacromial Pain Syndrome (CSAPS) is a common condition characterized by persistent shoulder pain and functional limitations. Despite existing non-operative treatments, patients often experience chronic pain, fear of movement (kinesiophobia) and impact shoulder function. The primary objective of this study is to evaluate the effects of extracorporeal shock wave therapy in conjunction with kinetic chain-based exercises on pain, kinesiophobia, and shoulder functional outcomes in individuals with CSAPS. Methodology: This case series included ten participants with unilateral shoulder pain lasting at least three months. Participants received extracorporeal shock wave therapy biweekly for six weeks alongside a structured kinetic chain exercise program. Outcome measures included the Numeric Pain Rating Scale for pain, the Tampa Scale for fear of movement, and the Shoulder Pain and Disability Index for functional assessment. Pre- and post-intervention data were analyzed using paired t-tests to determine statistical significance. Results and Discussion: Statistically significant improvements (p&lt;0.05) were observed after the intervention. The average NPRS score reduced from 7.5±0.84 to 1.90±0.99, showing a significant reduction in pain. The SPADI scores exhibited a significant improvement, decreasing from 66.79±9.48 to 51.90±8.90, indicating a reduction in both shoulder pain and disability. The TSK scores decreased from 48.10±3.03 to 37.60±4.47, indicating a decrease in kinesiophobia. Conclusion: The combination of ESWT and kinetic chain exercises resulted in significant enhancements in pain reduction, reduction in fear of movement, and improvement in shoulder function. This demonstrates the potential effectiveness of this integrated strategy in controlling CSAPS.

The Number of Patellar Dislocation Events Is Associated With Increased Chondral Damage of the Trochlea

Background: Patellofemoral instability is associated with chondral injuries to the patella, trochlea, and lateral femoral condyle. Although studies have demonstrated an association between patellar dislocations and chondral injuries, the influence of the number of dislocations on chondrosis is not established. Purpose: To elucidate the precise association between the number of patellar dislocation events and the severity of chondral injuries in a multicenter cohort study at the time of patellar stabilization procedures. Study Design: Cross-sectional study; Level of evidence, 2. Methods: A prospective multicenter cohort study (JUPITER [Justifying Patellar Instability Treatment by Early Results]) database was queried for cases of primary patellofemoral instability procedures from December 2016 to September 2022. Cartilage lesions were classified using the International Cartilage Repair Society (ICRS) classification system during an arthroscopic or open evaluation (direct visualization), with grades 2 to 4 considered abnormal. The number of dislocations was categorized as 1, 2-5, and >5. Categorical variables were compared with the chi-square test, and binary logistic regression was performed to identify predictors of the presence of chondral lesions. Results: A total of 938 knees (mean age, 16.2 ± 3.8 years; 61.4% female) were included, with 580 (61.8%) demonstrating a chondral injury. The most affected region was the patella (n = 498 [53.1%]), followed by the lateral femoral condyle (n = 117 [12.5%]) and trochlea (n = 109 [11.6%]). There were no differences in the presence (P = .17) or grade (P = .63) of patellar lesions by the number of dislocations. Patients with >5 dislocations more frequently had trochlear chondral lesions (19.8%) compared with those with fewer dislocations (1, 7.6%; 2-5, 11.0%; P < .001). More dislocations were also associated with a higher proportion of ICRS grade 2 to 4 trochlear lesions (>5, 15.3%; 2-5, 10.0%; 1, 6.9%; P = .015). Combined patellar and trochlear lesions were also more common in those with >5 dislocations (P = .001). In multivariable regression, >5 dislocations was the only variable predictive of a trochlear lesion (odds ratio, 3.03 [95% CI, 1.65-5.58]; P < .001). Conclusion: This large prospective cohort study demonstrated that recurrent patellar dislocations can lead to more severe chondral damage in specific locations in the knee. More than 5 dislocations was associated with a >3-fold increase in the incidence and severity of trochlear chondral injuries. There were no differences in the presence or grade of patellar lesions by the number of dislocations. These findings should caution surgeons regarding prolonged nonoperative treatment.

Appendicolith classification: physical and chemical properties of appendicoliths in patients with CT diagnosed acute appendicitis – a prospective cohort study

ObjectiveAppendicoliths are associated with a more complicated course of acute appendicitis and failure of non-operative treatment. We aimed to update the appendicolith classification originally described in 1966 and to assess...

Placebo Effect in the Treatment of Patellar Tendinopathy and Its Influencing Factors: Systematic Review With Meta-analysis and Meta Regression of Randomized Controlled Trials.

The effectiveness of nonsurgical treatment of patellar tendinopathy is questioned due to the conflicting results of placebo-controlled randomized controlled trials (RCTs) in which placebo arms often show impressive results. To quantify the magnitude of placebo effect of the different nonsurgical treatments of patellar tendinopathy. We also evaluated the influence of patients and treatments characteristics on the response to the placebo. Systematic review; Level of evidence, 1. We searched PubMed, Web of Science, Embase, Scopus, Cochrane Library, and gray literature databases on May 10, 2023, with no time limitation. RCTs on nonoperative treatment of patellar tendinopathy, including a placebo control arm reporting the evolution of symptoms after placebo administration, were included. A single-arm meta-analysis was performed with the Victorian Institute of Sport Assessment-Patella (VISA-P) at mid-term follow-up (3-6 months) as the primary outcome. The VISA-P score at short-term (1-3 months) and long-term (6-12 months) follow-ups, as well as visual analog scale (VAS) for pain at all 3 time points were also analyzed. A subanalysis based on the type of placebo and a meta-regression were conducted to look for potential determinants of the placebo effect. Risk of bias and level of evidence were also analyzed using the revised tool for risk of bias in randomized trials and Grading of Recommendations Assessment, Development and Evaluation. In total, 14 studies (251 patients) were included. VISA-P score at mid-term follow-up (3-6 months) showed statistically significant improvements of 13 of 100 points (P = .001). The change at short-term follow-up (1-3 months) was not statistically significant, whereas at long-term follow-up (6-12 months) it was 27 of 100 points (P < .001). Regarding VAS, results were statistically significant only at mid-term (MD = -1.5/10; P = .02) and long-term (MD = -3.2/10; P < .001) follow-ups. The meta-regression showed positive correlations between the response to placebo and the follow-up length (P < .001) and the effect size in the experimental group (P = .006). The level of evidence was moderate for mid- and long-term results and low for short-term results. The placebo effect for nonsurgical treatments of patellar tendinopathy is long-lasting (up to 12 months) and statistically and clinically significant. It has a perceived and true component and differs among treatments. The duration of follow-up and the effect size of experimental groups correlate with the magnitude of the placebo component, underlining the importance of RCTs to determine the effectiveness of new treatments of patellar tendinopathy.

Effectiveness of non-operative treatment in patients with glenohumeral osteoarthritis: a prospective cohort study

Effectiveness of non-operative treatment in patients with glenohumeral osteoarthritis: a prospective cohort study

Magnetic Resonance Imaging Has Utility in Clinical Decision-Making for Children and Adolescents With Symptomatic Subfibular Ossicles.

We performed a retrospective study of pediatric patients with lateral ankle pain, recurrent sprains, and radiographs showing SOs who had undergone an MRI as part of their diagnostic work-up.We identified 22 patients from the senior author's registry of pediatric patients with lateral ankle injuries. Eleven were girls, and 11 were boys, ages ranging from five to 19 years.Eleven involved the left ankle; 11 involved the right. Positive MRIs showed a high-intensity signal between the SO and the distal fibular epiphysis; negative MRIs had a low-intensity signal. The main outcome measure was operative versus non-operative treatment. Sixteen of the 22 patients had positive MRIs, and six had negative MRIs. Twelve of the 16 patients with positive MRIs had undergone an operation. All six patients with negative MRIs responded to nonoperative management. MRI has utility in clinical decision-making for symptomatic patients with SOs.Patients with negative MRI sequences responded to nonoperative management.Most patients with positive MRI sequences will require surgery to alleviate their symptoms and return to full activities. IV.