Nonoperative Therapies Research Articles

What Affects Healing Rates in Patients Treated for Medication-Related Osteonecrosis of the Jaw? The Role of Operative Therapy and Other Clinical Factors

BackgroundIn the therapy of medication-related osteonecrosis of the jaw (MRONJ), the healing rate, effectiveness of operative therapy, and factors associated with healing remain unclear. PurposeThis study aimed to estimate MRONJ therapy healing rates and identify associated prognostic factors. Study design, setting, sampleA 25-center prospective cohort study was conducted on 291 patients with MRONJ treated with a common therapeutic protocol during 2013–2016. Patients unable to continue examinations or treatment were excluded. Predictor variableThe primary predictor variable was MRONJ therapy grouped into two categories: operative and nonoperative. Secondarily, the prognostic factors categorized as demographic, medical, clinical, and perioperative were evaluated. Main outcome variablesThe primary outcome variable was treatment duration, defined as the time (in months) between the initiation of therapy and when the site was healed or the date of the final visit or loss to follow-up. CovariatesNot applicable. AnalysesDescriptive statistics and 3-year cumulative healing rates were calculated. The association between clinical factors and time to healing were analyzed using bivariate and multivariate analyses and propensity score analysis. P < .05 was considered significant. ResultsWe analyzed data from 291 subjects with 76 (26.1%) and 215 (73.9%) subjects in the operative and nonoperative therapy groups, respectively. The healing rates for operative and nonoperative therapies were 95.8% and 70.7%, respectively (hazard ratio [HR] = 1.6, 95% confidence interval [CI] = 1.1–2.2, P-value [P] < .01). The healing rates in patients for whom anti-resorptive agent (ARA) treatment was discontinued and continued were 87.2% and 37.4%, respectively (HR = 1.8, 95% CI = 1.1–3.0, P = .02). In a multiple regression analysis using ARA indication, the therapy method showed a significant association in the MRONJ malignancy group (HR = 2.75, 95% CI = 1.46–5.17, P < .01). Conclusions and RelevanceOperative therapy and ARA discontinuation were associated with better healing rates in MRONJ therapy. However, the choice of therapy for MRONJ should be based on a comprehensive consideration of the patient’s condition. ARA discontinuation should be considered an adjunctive measure because of the possibility of adverse events such as fragility fractures and skeletal related events.

New horizons in cartilage repair: update on treatment trends and outcomes

IntroductionArticular cartilage plays a crucial role in preserving the knee joint's structural integrity. Damage can manifest as focal chondral defects or progressive osteoarthritis. Treatment options for knee cartilage damage are multifaceted, encompassing surgical and nonsurgical interventions to repair defects, alleviate symptoms, restore function, and slow disease progression. ObjectivesGain insight and summarize the latest available evidence of knee joint preservation techniques. MethodsThe indications, outcomes, and biological characteristics of operative and nonoperative knee cartilage repair and joint preservation therapies were summarized. ResultsOsteochondral autologous transplantation and osteochondral allograft transplantation offer durable solutions with excellent long-term outcomes. Autologous chondrocyte implantation and matrix-induced autologous chondrocyte implantation are advanced, cell-based therapies effective for larger defects, especially in younger, active individuals. Non-operative therapies such as hyaluronic acid provide symptomatic relief for knee osteoarthritis. Bone marrow aspirate concentrate and platelet-rich plasma show efficacy in alleviating symptoms and improving joint function, presenting a minimally invasive approach with promising results for knee preservation and cartilage repair. ConclusionThe use of minimally invasive and nonsurgical interventions in addressing focal cartilage defects, osteoarthritis, and overall joint preservation has yielded varied results. Although recent literature has exhibited encouraging findings, the existing body of high-level evidence remains limited. The emerging evidence inspires optimism for the future, as medical practitioners shift focus to the next wave of knee cartilage repair and joint preservation methodologies. However, comprehensive research is essential to establish conclusive insights into outcomes, safety profiles, and comparative effectiveness among the diverse available treatments.

Contributions of the Abductor Muscles to Rotational and Distractive Stability of the Hip in a Biomechanical Cadaveric Model.

The gluteus minimus (GMin) and gluteus medius (GMed) are important dynamic stabilizers of the hip, but quantitative data on their biomechanical roles in stabilizing the hip are currently lacking. To (1) establish a reproducible biomechanical cadaveric model of the hip abductor complex and (2) characterize the effects of loading the GMin and GMed on extraneous femoral rotation and distraction. Controlled laboratory study. A total of 10 hemipelvises were tested in 4 muscle loading states: (1) unloaded, (2) the GMin loaded, (3) the GMed loaded, and (4) both the GMin and GMed loaded. Muscle loads were applied via cables, pulleys, and weights attached to the tendons to replicate the anatomic lines of action. Specimens were tested under internal rotation; external rotation; and axial traction forces at 0°, 15°, 30°, 60°, and 90° of hip flexion. When loaded together, the GMin and GMed reduced internal rotation motion at all hip flexion angles (P < .05) except 60° and reduced external rotation motion at all hip flexion angles (P < .05) except 0°. Likewise, when both the GMin and GMed were loaded, femoral distraction was decreased at all angles of hip flexion (P < .05). The results of this study demonstrated that the GMin and GMed provide stability against rotational torques and distractive forces and that the amount of contribution depends on the degree of hip flexion. Improved understanding of the roles of the GMin and GMed in preventing rotational and distractive instability of the hip will better guide treatment of hip pathologies and optimize nonoperative and operative therapies.

Diagnosis and Management of Lower Extremity Chronic Exertional Compartment Syndrome in the Active Adult Population

Chronic exertional compartment syndrome can significantly alter the quality of life and level of physical activity participation in active adults. This lesser known and understood condition requires diligent physical examinaion and linear diagnostic progression to appropriately diagnose. Although surgical intervention is the definitive treatment modality, there are multiple surgical approaches which could be considered and several nonoperative conservative therapies which can be trialed to meet patients' physical performance goals.

Surgical Treatments for Osteoarthritis.

Osteoarthritis is a prevalent and disabling condition most commonly affecting the knees, hips, and hands. Since there are currently no disease-modifying therapies available, patients with persistent pain and functional impairment despite pharmacologic and other non-operative therapies should be considered for surgical management. For both knee and hip Osteoarthritis, the most common surgical approach is total joint arthroplasty, an elective surgical procedure that generally has favorable outcomes with most patients reporting significant improvements in pain, function, and quality of life. Total joint arthroplasty has relatively low complication rates, with most patients able to be discharged home following a short hospital stay. The optimal timing for undergoing total joint arthroplasty and patient appropriateness for surgery are important considerations, and the current guidelines leave timing and patient selection at the discretion of physicians. Surgical approaches for hand osteoarthritis are less common and more varied, and include both arthrodesis and arthroplasty.

HPB P28 Continuous glucose monitoring improves the diagnosis of insulinoma and surveillance after endoscopic ablation therapy

Abstract Background Insulinomas are the most common functioning pancreatic neuroendocrine tumours (PNET) and are classically diagnosed according to Whipple’s triad. The gold-standard diagnostic test (72 hour fasting glucose/C-peptide) is difficult for patients, and risks mis-diagnosing patients who only experience post-prandial symptoms. Moreover, the advent of endoscopic ablative techniques means that confirming successful treatment can be challenging when compared with surgical resection. This study aimed to investigate the value of continuous glucose monitoring (CGM) to: a) confirm the diagnosis of insulinoma; b) guide symptom management whilst awaiting definitive treatment; and c) as a surveillance tool in patients electing for non-surgical interventions. Methods A 61-year-old healthy male presented with post-prandial sweating, vacant episodes and reduced exercise tolerance which resolved upon consuming glucose. Computed Tomography demonstrated a 2cm exophytic hypervascular lesion in the pancreatic body, consistent with a NET, and correlated with an Octreotide avid lesion upon SPECT/CT. Overnight fasting glucose/c-peptide was not confirmatory. The target glucose range was defined as 4.0-9.9 mmol/L and critical hypoglycaemia as ≤2.9mmol/L. Data from CGM were analysed (Time in range and critical hypoglycaemia [Chi2]; glycaemic control and glycaemic variability [T-test]) during diagnosis, in the first week post-ablation, and the recovery phase beyond 3 weeks. Results Data from 22,008 glucose levels were analysed over a 90 day period. Time in range during diagnosis was 67.25%, 82.8% (p&amp;lt;0.0001) post-ablation, and 98.9% (P&amp;lt;0.0001) during recovery. Critical hypoglycaemia occurred in 5.2% of measurements during diagnosis, 1.9% (p&amp;lt;0.0001) post-ablation, and 0.1% (p&amp;lt;0.0001) during recovery. Glucose levels (mean [SD] mmol/L) were 4.4 (0.47) during diagnosis, 4.9 (0.29) (p=0.0001) post-ablation, and 5.7 (0.42) (p&amp;lt;0.0001) during recovery. Glycaemic variability (mean [SD] %CV) was 19.4 (5.09) during diagnosis, 20.17 (5.60) post-ablation (p=0.630), and 11.3 (5.53) (p&amp;lt;0.0001) during recovery. Temporal changes identifying post-prandial hypoglycaemia during diagnosis, and resolution during recovery, are illustrated (Figure 1). Conclusions CGM has utility to accurately diagnose insulinoma when standard tests are negative, and to improve quality of life by alerting patients to life-threatening critical hypoglycaemia. As parenchymal preserving non-operative therapies increase in popularity, especially for patients with small PNETs, sensitive, reliable, and acceptable surveillance techniques are required in order to confirm treatment success and monitor for recurrence. Proactive engagement with commissioning and regulatory bodies is necessary in order to harness the potential from emerging technologies, so that PNET patients can benefit in a similar manner as those with type 1 Diabetes Mellitus.

Gluteal Tendinopathy: Critical Analysis Review of Current Nonoperative Treatments.

» Gluteal tendinopathy/greater trochanteric pain syndrome (GTPS) is the most prevalent of all lower limb tendinopathies, affecting 1 in 4 women older than 50 years and commonly individuals within their fifth and sixth decades of life regardless of activity level.» The condition is believed to originate from age-related degenerative changes about the hip abductor tendon insertions and the surrounding bursae, and is exacerbated by congenital and acquired abnormal hip biomechanics.» Treatment of gluteal tendinopathy/GTPS often begins with noninvasive nonoperative modalities such as activity modifications, nonsteroidal anti-inflammatory drugs, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies have been used; however, there remains a lack of comparative efficacy between these adjunct treatments.» In this article, we examine the available literature regarding the nonoperative management of gluteal tendinopathy/GTPS and provide insight into the effectiveness of current treatment modalities.

Advances in Photoelectric Therapy for the Early Intervention and Treatment of Traumatic Scars.

Traumatic scar is a disease that affected approximately tens of millions of patients worldwide. According to the histological and morphological properties of scars, the traumatic scar typically includes superficial scar, atrophic scar, hypertrophic scar, and keloid. Its formation is a natural consequence of wound healing, regardless of whether the wound was caused by trauma or surgery. However, the production of scars has considerable impacts on the physical and mental health of patients, even causing substantial aesthetic and functional impairments. Prevention or early treatment of scars is the most suitable therapeutic method, including surgical and non-surgical procedures; nevertheless, the benefits of non-operative therapies for scars are quite limited, and surgical treatments are always hard to achieve satisfying outcomes. Through the application of innovative technologies such as lasers, intense pulsed light, and radiofrequency, significant progress has been made in the treatment of traumatic scars. This review highlights the current advancements of photoelectric therapy for the prevention and treatment of various traumatic scars, which may throw light on innovative therapeutic options for scar therapies.

Multiple primary lung cancer: Updates of clinical management and genomic features.

In recent decades, multiple primary lung cancer (MPLC) has been increasingly prevalent in clinical practice. However, many details about MPLC have not been completely settled, such as understanding the driving force, clinical management, pathological mechanisms, and genomic architectures of this disease. From the perspective of diagnosis and treatment, distinguishing MPLC from lung cancer intrapulmonary metastasis (IPM) has been a clinical hotpot for years. Besides, compared to patients with single lung lesion, the treatment for MPLC patients is more individualized, and non-operative therapies, such as ablation and stereotactic ablative radiotherapy (SABR), are prevailing. The emergence of next-generation sequencing has fueled a wave of research about the molecular features of MPLC and advanced the NCCN guidelines. In this review, we generalized the latest updates on MPLC from definition, etiology and epidemiology, clinical management, and genomic updates. We summarized the different perspectives and aimed to offer novel insights into the management of MPLC.

Lateral Epicondylitis: Critical Analysis Review of Current Nonoperative Treatments.

Lateral epicondylitis (LE) or tennis elbow is a common cause of elbow pain in the general population, especially women in the fourth and fifth decades of life who participate in repetitive forceful movements involving the wrist and forearm. The pathogenesis of this overuse injury is believed to start from an overload event leading to a microtear in or near the origin of the extensor carpi radialis brevis that is subsequently prone to additional injury and structural weakness over time. Treatment of LE often begins with a wide variety of nonoperative modalities including rest, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies are implemented; however, there remains a lack of comparative efficacy between these adjunct treatments. In this article, we examine the available literature regarding nonoperative management of LE and provide supplementary insight into the effectiveness of current modalities.

Leucine rich repeat containing 32 accelerates tenogenic differentiation of tendon-derived stem cells and promotes Achilles tendon repair in rats.

Although many surgical or non-operative therapies have been developed to treat Achilles tendon injuries, the prognosis of which is often unsatisfactory. Recently, biologic approaches using multipotent stem cells like tendon-derived stem cells (TDSCs) pose a possible treatment option. To evaluate whether the Leucine rich repeat containing 32 (Lrrc32) affects the tenogenic differentiation of TDSCs and thus promotes Achilles tendon healing. TDSCs were infected with the recombinant Lrrc32-overexpressing lentivirus (LV-Lrrc32) and then locally injected into the injured site of rat. Four weeks after surgery, the Achilles tendon tissue (~0.5 cm) around the injured area was harvested for analysis. Pathological results showed that Lrrc32-overexpressing TDSCs significantly improved the morphological changes of the injured tendons. Specifically, the increased collagen-I expression and hydroxyproline content in extracellular matrix, and more orderly arrangement of the regenerated collagen fibers were observed in the Lrrc32 overexpression group. Moreover, 4 weeks after injection of Lrrc32-overexpressing TDSCs, the expression of tenocyte-related genes such as tenomodulin (Tnmd), scleraxis (Scx) and decorin (Dcn) were upregulated in the area of the healing tendon. These findings indicated that Lrrc32 promoted the tenogenic differentiation of TDSCs in vivo. Additionally, Lrrc32 overexpression also increased the expression of TGF-β1 and p-SMAD2/3, suggesting that the beneficial effects of Lrrc32 on tendon repair might be associated with the expression of TGF-β1 and p-SMAD2/3. Our findings collectively revealed that Lrrc32-overexpressed TDSCs promoted tendon healing more effectively than TDSCs alone.

232. Inhibition of neurogenic inflammatory pathways associated with reduction in discogenic back pain

<h3>BACKGROUND CONTEXT</h3> Calcitonin gene-related peptide (CGRP), a neuropeptide found in abundance at the interface between blood vessels and sensory nerve fibers, upregulates pro-inflammatory cytokines including tumor necrosis factor-α, interleukin-6, brain derived neurotrophic factor, and nerve growth factor in spinal spondylotic disease resulting in disc degeneration and sensitization of nociceptive neurons. While the new class of anti-CGRP medications have proven ability to quell neurogenic inflammation in migraines, their off-site efficacy as a therapeutic target for discogenic back/neck pain conditions remains unknown. <h3>PURPOSE</h3> Utilizing a patient population with comorbid degenerative spinal disease and migraines, this study aims to determine if initiation of anti-CGRP biologic treatment for migraines was also associated with improvements in back/neck pain, mobility, and function. <h3>STUDY DESIGN/SETTING</h3> Retrospective case series. <h3>PATIENT SAMPLE</h3> All patients over age 18 with concomitant spinal spondylosis and migraine diagnoses treated with anti-CGRP medications at a single academic institution between 2017-2020 were retrospectively identified. Patients with history of spinal surgery, malignancy, cervicogenic headache, new narcotic prescriptions or inconsistent anti-CGRP use were excluded. <h3>OUTCOME MEASURES</h3> Clinical spine outcomes before and after anti-CGRP medication initiation including pain, mobility and functional status. <h3>METHODS</h3> Patient demographic (age, sex, race, smoking status, BMI) and medical (CCI, depression, anxiety, fibromyalgia) data, follow-up duration, migraine severity and frequency, spine pain, functional status, and mobility before and after anti-CGRP medication initiation were collected. Paired univariate analysis tested for significant changes in spine pain, headache severity, and headache frequency before and after beginning anti-CGRP. Correlation between changes in spine pain score and functional or mobility improvement were assessed with the Spearman's rho coefficient. <h3>RESULTS</h3> A total of 56 patients were included. The mean follow-up time after anti-CGRP initiation was 123 days for spine visits and 129 days for migraine visits. Back/neck pain decreased significantly (p<0.001) from 6.30 to 4.36 after starting anti-CGRP medication for migraine control. As recorded in the spine follow-up notes, 25% of patients experienced functional improvement in ADLs and 17.5% of patients experienced mobility improvement while taking anti-CGRP medication. Change in back/neck pain demonstrated a moderate correlation (ρ= -0.430) with functional improvement but no correlation with mobility improvement (ρ= -0.052). <h3>CONCLUSIONS</h3> Patients receiving anti-CGRP treatment for chronic migraines with comorbid degenerative spine conditions experienced significant off-target back/neck pain reduction. Future interventional studies are necessary to explore the effectiveness of this novel medication class in all patients with discogenic back/neck pain that is recalcitrant to standard nonoperative therapies. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Outcomes in Pediatric Hip FAI Surgery: a Scoping Review

Femoracetabular impingement (FAI) is a common source of hip pain in children and adolescents. While nonoperative therapies and open surgical procedures can be effective, hip arthroscopy is a minimally invasive treatment option with substantial benefit. The purpose of this paper is to evaluate the current role of hip arthroscopy in treating FAI within the pediatric population. This article examines its efficacy through a review of hip arthroscopy outcomes in the contemporary orthopaedic literature. Morphologic changes in the acetabulum and proximal femur seen in FAI can be attributed to a multitude of etiologies-including idiopathic FAI, Legg-Calve-Perthes, and slipped capital femoral epiphysis. In general, arthroscopic treatment of FAI secondary to these conditions leads to statistically significant improvements in pain and patient-reported outcomes in the short and long term. In the pediatric athlete, repetitive stress on the hip perpetuates FAI and can drastically hinder performance. Hip arthroscopy allows for a high rate of return to sport with minimal morbidity in this population. Overall, pediatric hip arthroscopy is effective in treating FAI secondary to a wide variety of conditions. Despite its clinical benefits, patients and their families should be counseled regarding alternative treatments, potential complications, and return to play.

Management of hepatocellular carcinoma in patients who are 70 years or older

BackgroundAlthough liver transplantation has been done successfully in elderly patients with hepatocellular carcinoma, these are likely well-selected patients. This study uses a large database of patients with hepatocellular carcinoma to explore treatment and potential candidacy for liver transplantation in the elderly. MethodsRetrospective review of 1,533 hepatocellular carcinoma cases identified 2 groups: 475 patients 70 years or older (70+) and 1,058 patients <70 years. Demographics, risk factors, tumor characteristics, treatments, and survival were compared. Three- and 5-year survival rates were determined, and logistic regression was used to identify factors predictive of 3-year survival. ResultsPatients 70+ were more likely to have metabolic factors and less likely to have viral hepatitis, cirrhosis, hepatocellular carcinoma found with surveillance (21.7% vs 28.4%, P = .005), and hepatocellular carcinoma within Milan criteria (37.3% vs 43.8%, P = .019). Model for End-stage Liver Disease score was similar, but patients 70+ had higher mean creatinine and lower mean bilirubin. Patients 70+ were equally likely to undergo liver resection but less likely to undergo liver transplantation (0.4% vs 10.2%, P < .001). Three- and 5-year survival rates were significantly worse in 70+, and predictors of 3-year survival included hepatocellular carcinoma found with surveillance, meeting Milan criteria, and normal alpha fetoprotein. DiscussionElderly patients with hepatocellular carcinoma were less likely to undergo liver transplantation potentially due to metabolic factors and advanced disease. Although there is no age cutoff for liver transplantation, elderly patients should be given realistic expectations of liver transplantation candidacy. Continued surveillance for hepatocellular carcinoma in elderly patients may allow for earlier diagnosis and improved liver transplantation candidacy. Key MessageHepatocellular carcinoma in patients who are 70 years or older can be managed with liver transplantation in select cases, but more patients will be managed with liver resection and nonoperative therapies.

Mid-term Results of the Treatment of Isolated Dissection of the Celiac Artery: A Comparative Analysis of Endovascular Versus Conservative Therapy

Objectives: Endovascular treatment (EVT) is an alternative method used to treat isolated dissection of the celiac artery (IDCA). However, only a few mid-term results have been reported. This study aimed to analyze and compare the outcomes of endovascular and non-operative therapies for IDCA. Methods: Data from a cohort of consecutive IDCA patients enrolled in the study hospital between April 2012 and September 2020 were retrospectively reviewed. Demographic information, imaging features, treatment modalities, and follow-up results of celiac artery remodeling and adverse events were collected and analyzed. Results: A total of 87 patients were enrolled in the study. Stents were deployed in 68 patients, and non-operative treatment (blood pressure control and pain management) was continued in the remaining 19 patients who did not receive stenting; among these 19 patients, EVT failed in 6. The mean follow-up period was 37.3 (range, 10–85 months) and 44.0 (range, 9–80 months) months in the EVT and non-operative groups, respectively. During follow-up, the overall complete remodeling (absence of residual dissection with no false lumen or no intramural thrombus) rate was significantly higher in the EVT group than in the non-operative group (87.3% vs 7.1%, p<0.001). The incomplete remodeling (improved true lumen with malabsorption or partial thrombosis of the false lumen) rate was not significantly different between the EVT and non-operative groups (6.3% vs 14.3%; p=0.2984). Meanwhile, the adverse event-free survival rates were 89.0%, 67.0%, and 67.0% at 1, 3, and 5 years, respectively, in the EVT group compared with 39.7% and 29.8% at 1 and 3 years in the non-operative group (p<0.0001). Conclusions: EVT for IDCA may be considered an effective management option with a favorable clinical success rate, an encouraging complete remodeling rate, and a satisfactory adverse event-free survival rate. However, further evaluation with a long-term follow-up is required. Clinical Impact Endovascular intervention for isolated dissection of the celiac artery has attracted inadequate attention. In this retrospective study with comparative analysis of endovascular versus conservative therapy for isolated dissection of the celiac artery patients, a better complete remodeling rate and a higher adverse event-free survival rate were observed in the endovascular treatment (EVT) group during follow-up, indicating that EVT could be an effective management option for isolated dissection of the celiac artery.

In Patients with Displaced Type-II Distal Clavicle Fractures, Operative and Nonoperative Therapies Did Not Differ for Functional Outcomes at 1 Year

1Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts Disclosure: The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (https://links.lww.com/JBJS/H84).

Decompressive Craniectomy Practice following Traumatic Brain Injury in Comparison with Randomized Trials: Harmonized, Multi-Center Cohort Studies in Europe, the United Kingdom, and Australia

High quality evidence shows decompressive craniectomy (DC) following traumatic brain injury (TBI) may improve survival but increase the number of severely disabled survivors. Contemporary international practice is unknown. We sought to describe international use of DC, and the alignment with evidence and clinical practice guidelines, by analyzing the harmonized Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) and Australia-Europe NeuroTrauma Effectiveness Research in Traumatic Brain Injury (OzENTER-TBI) core study datasets, which include patients admitted to intensive care units (ICUs) in Europe, the United Kingdom, and Australia between 2015 and 2017. Outcomes of interest were treatment with DC relative to clinical trial evidence and the Brain Trauma Foundation guidelines. Of 2336 people admitted to ICUs following TBI, DC was performed in 320 (13.7%): in 64/1422 (4.5%) patients with diffuse TBI and 195/640 (30.5%) patients with traumatic mass lesions. Secondary DC (for treatment of intracranial hypertension) was used infrequently in patients who met enrollment criteria of the two randomized clinical trials informing the guidelines-specifically, in 11/124 (8.9%) of those matching Decompressive Craniectomy in Diffuse Traumatic Brain Injury trial (DECRA) enrollment, and in 30/224 (13.4%) of those matching Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp). Of patients who underwent DC, 258/320 (80.6%) were ineligible for either trial: 149/320 (46.6%) underwent primary DC, 62/320 (19.4%) were outside the trials' age criteria, and 126/320 (39.4%) did not develop intracranial hypertension refractory to non-operative therapies prior to DC. Secondary DC was used infrequently in patients in whom it had been shown to increase survival with severe disability, indicating alignment between contemporaneous evidence and practice. However, most patients who underwent DC were ineligible for the key trials; whether they benefited from DC remains unknown.

The Efficacy of Intra-articular Subtalar Steroid Injection for Symptomatic Talocalcaneal Coalitions: A 30-Year Single Institution Experience.

While intra-articular steroid injection has been used anecdotally in patients with symptomatic talocalcaneal coalitions recalcitrant to traditional conservative modalities, the ability of this treatment to provide symptomatic relief and obviate or delay surgical intervention remains unknown. The purpose of this study is, therefore, to assess the treatment efficacy of intra-articular subtalar steroid injection in children with symptomatic talocalcaneal coalitions. A retrospective study of all patients with isolated subtalar coalitions was performed at a single pediatric orthopaedic institution over a 30-year period. Radiographs were analyzed to identify the type of coalition (osseous or nonosseous), presence of any posterior facet involvement, and presence of a planovalgus foot deformity. Patients who underwent a subtalar joint steroid injection after failing other conservative treatments were identified and compared with those who did not receive an injection as part of their nonoperative management with regard to the need for ultimate surgical intervention and the time from presentation to surgery when applicable. A total of 83 patients (125 feet) met inclusion criteria, of whom 25 patients (34 feet) received a subtalar steroid injection. When compared with the 58 patients (91 feet) treated with standard nonoperative modalities, there were no differences with regard to sex, age at presentation (12.4 and 12.3 y, respectively), facet involvement, type of coalition, or the presence of a planovalgus deformity. In all, 12/34 (35%) feet in the injection group eventually elected surgical intervention compared with 36/91 (39%) feet that did not receive an injection (P=0.72). For those patients ultimately selecting surgical intervention, the average time from initial presentation to surgery was 878 days in the injection group versus 211 days in the noninjection group (P<0.001). While subtalar steroid injection can alleviate symptoms in some patients with a talocalcaneal coalition, this intervention does not appear to decrease the need for surgery when compared with traditional nonoperative therapies. In patients failing other forms of conservative treatment, subtalar steroid injections can delay surgical intervention by an average of nearly 2 years. Level-III-therapeutic study.

Contemporary Management of Abdominal Aortic Aneurysms.

Abdominal aortic aneurysms (AAA) can carry extremely high mortality rates and most will only present with symptoms with impending rupture. We present an overview of management of this disease process starting with screening, to medical management, surveillance and treatment options currently available, as well as those being studied for future use. Screening has been proven to reduce the mortality rate. There still remains a paucity of data to support medical therapies to help mitigate the rate of aneurysm growth and prevent rupture. However, on the topic of repair, there have been advancements in endovascular devices which have broadened the scope of treatment for patients with anatomy not amenable to standard endovascular repair or those who are not suitable candidates for open surgical repair. Appropriate surveillance, risk factor modification, and operative repair, when indicated, are the cornerstones of contemporary management of AAAs. Advancements in endovascular technologies have allowed us to treat more patients. Further research is warranted on non-operative medical therapies.

The Application and Patient-Reported Experience of Telephone Consultations in Elective Foot and Ankle Orthopaedic Surgery: 12-Month Follow-up.

Telemedicine offers convenient and affordable health care, overcoming the logistical challenges of face-to-face encounters. Clinicians increasingly relied on telemedicine during the global pandemic. To assess the ongoing role for telemedicine in orthopaedics, we prospectively analyzed the failure rate, safety and patient-reported experience of telephone consultations for 12 months. 265 telephone Foot/Ankle consultations were conducted in April 2020 and were prospectively analyzed over 12 months. The primary outcome measure was the rate of failed telephone consultations. A consultation was deemed unacceptable if the patient did not answer, if the clinician could not reach a conclusion or if any outcome changed over 12 months. Secondary outcome measures included patient-reported satisfaction and time saved by avoiding a face-to-face visit. A clinical decision was reached in 84% of follow-up telephone consultations and 64% of new patient consultations (P = 0.001). Sixty-six percent were managed with nonoperative therapies, 16% were discharged, and 11% were added to the waiting list for surgery. The reasons for failing to achieve a clinical decision included failure to contact the patient (12.8%), inappropriate discharge with subsequent rereferral (1.9%), and insufficient clinical information (1.5%). Overall, 84.7% of patients reported that the telephone consultation was highly useful and 71.9% would recommend it to a friend or family member. Patients reported a mean time saving of 120 minutes. Based on our experience, we provide recommended criteria for the safe and practical use of telephone consultations and suggest versatile patient care pathways into which a telephone consultation can be incorporated. Level IV, prospective cohort series (noncomparative).