Nonoperative Treatment Options Research Articles

A physiatrist's understanding and application of the current literature on chronic pelvic pain: a narrative review.

Chronic pelvic pain (CPP) is a highly prevalent condition which is underdiagnosed and poorly understood. The purpose of this review is to outline the various aspects of the nature of CPP, including its etiologies, clinical presentation, and nonoperative treatment options. For data collection, a PubMed search was conducted using indexing terms such as chronic pelvic pain and pelvic pain. Literature reviews and studies focusing on etiologies, clinical presentation, and/or the diagnosis of CPP were compiled for review by a team of 3 physiatrists. Studies investigating conservative treatments, medications, and interventional procedures for CPP and related conditions with comparable etiologies were also included. Of the 502 articles retrieved, 116 were deemed suitable by the team for this study. Although CPP is a complex, multifaceted condition, a particular susceptibility to nociceptive stimuli was demonstrated as an underlying theme in its evolution. There are many treatment options currently used; however, more robust evidence, such as randomized controlled trials, are needed before creating comprehensive guidelines for treating CPP.

Plantar Fasciitis: Distal Tarsal Tunnel (Baxter's Nerve) in the Athlete

Plantar medial inferior heel pain is a common complaint in athletes and is frequently caused by plantar fasciitis and/or distal tarsal tunnel syndrome (Baxter's neuropathy). Obtaining an accurate diagnosis is crucial but may be challenging due to a similar site of pain and overlapping symptoms. While both conditions often resolve with nonoperative management, they may present with a prolonged symptomatic course that can last 10-12 months. Consequently, providers treating athletes should understand the various therapies proposed to address these pathologies as no one optimal treatment strategy has emerged. Stretching exercises, orthotic devices, extracorporeal shock wave therapy , plasma-rich protein injections, and endoscopic plantar fascia release have garnered the most attention for the management of plantar fasciitis. Rest, non-steroidal anti-inflammatories , and open distal tarsal tunnel release have been employed for the treatment of Baxter's neuropathy. This review summarizes recent literature on the diagnosis, numerous nonoperative treatment options, and surgical management of plantar fasciitis and distal tarsal tunnel syndrome.

Relative Efficacy of Intra-articular Injections in the Treatment of Knee Osteoarthritis: A Systematic Review and Network Meta-analysis

Background: In younger patients and those without severe degenerative changes, the efficacy of intra-articular (IA) injections as a nonoperative modality for treating symptomatic knee osteoarthritis (OA)–related pain while maintaining function has become a subject of increasing interest. Purpose: To assess and compare the efficacy of different IA injections used for the treatment of knee OA, including hyaluronic acid (HA), corticosteroids (CS), platelet-rich plasma (PRP), and plasma rich in growth factors (PRGF), with a minimum 6-month patient follow-up. Study Design: Meta-analysis of randomized controlled trials; Level of evidence, 1. Methods: A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Mean or mean change from baseline and standard deviation for outcome scores regarding pain and function were recorded at the 6-month follow-up and converted to either a 0 to 100 visual analog scale score for pain or a 0 to 100 Western Ontario and McMaster Universities Osteoarthritis Index score for function. A frequentist network meta-analysis model was developed to compare the effects of HA, CS, PRP, PRGF, and placebo on patient-reported outcomes. Results: All IA treatments except CS were found to result in a statistically significant improvement in outcomes when compared with placebo. PRP demonstrated a clinically meaningful difference in function-related improvement when compared with CS and placebo due to large effect sizes. Studies evaluating outcomes of PRGF reported significant improvement when compared with placebo due to large effect sizes, whereas a potential clinically significant difference was detected in the same comparison parameters in pain evaluation. With regard to improvements in pain, function, and both combined, PRP was found to possess the highest probability of efficacy, followed by PRGF, HA, CS, and placebo. Conclusion: PRP yielded improved outcomes when compared with PRGF, HA, CS, and placebo for the treatment of symptomatic knee OA at a minimum 6-month follow-up. Further investigations evaluating different IA and other nonoperative treatment options for patients with knee OA are warranted to better understand the true clinical efficacy and long-term outcomes of nonsurgical OA management.

Sacroiliac joint dysfunction: pathophysiology, diagnosis, and treatment.

To review the anatomy and function of the sacroiliac joint (SIJ), as well as the pathophysiology, clinical presentation, diagnostic criteria, and treatment options for SIJ dysfunction. The SIJ serves an extremely crucial function in mobility, stability, and resistance against shear forces. Joint mobility becomes increasingly limited with age-related cartilaginous changes that begin in puberty and continue throughout life. Pain can also be localized to the SIJ itself, known as SIJ dysfunction. A literature review was performed on the anatomy, etiology, risk factors, diagnostic modalities, and treatment options for SIJ dysfunction. SIJ dysfunction is an under-recognized source of low back pain. Dysfunction can result from various clinical conditions, as well as abnormal motion or malalignment of the joint. Diagnosis and evaluation of SIJ dysfunction are difficult, with use of physical maneuvers and image-guided anesthetic injection. Non-operative treatment options are considered first-line due to high surgical complication rates. Such options include conservative management, radiofrequency treatment, nerve blocks, and articular injections. Surgical management involves open and percutaneous approaches. With the aging nature of the population, SIJ dysfunction has emerged as an extremely prevalent issue. Current research into the pathophysiology and risk factors of SIJ dysfunction is extremely important for planning preventative and therapeutic strategies. Various treatment options exist including conservative management, radiofrequency, nerve blocks, intra-articular or peri-articular injections, and surgical fixation. Improved diagnostic methods in clinical practice are thus critical to properly identify patients suffering from SIJ dysfunction, plan early intervention, and hasten return to function. Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Diagnosis and Treatment of Snapping Scapula Syndrome: A Scoping Review.

Context:Snapping scapula syndrome (SSS) is commonly misdiagnosed and underreported due to lack of awareness.Objective:This scoping review aims to summarize the current evidence related to SSS diagnosis and treatment to aid clinicians in managing the condition more effectively.Data Sources:PubMed, Medline, and Embase databases were searched for studies related to the etiology, diagnosis, or treatment of SSS (database inception to March 2020).Study Selection:Databases were searched for available studies related to the etiology, diagnosis, or treatment of SSS.Study Design:A scoping review study design was selected to explore the breadth of knowledge in the literature regarding SSS diagnosis and treatment.Level of Evidence:Level 4.Data Extraction:Primary outcomes abstraction included accuracy of diagnostic tests, functional outcomes, and pain relief associated with various nonoperative and operative treatment options for SSS.Results:A total of 1442 references were screened and 40 met the inclusion criteria. Studies commonly reported SSS as a clinical diagnosis and relied heavily on a focused history and physical examination. The most common signs reported were medial scapular border tenderness, crepitus, and audible snapping. Three-dimensional computed tomography had high interrater reliability of 0.972, with a 100% success rate in identifying symptomatic incongruity of the scapular articular surface. Initial nonoperative treatment was reported as successful in most symptomatic patients, with improved visual analogue scale (VAS) scores (7.7 ± 0.5 pretreatment, to 2.4 ± 0.6). Persistently symptomatic patients underwent surgical intervention most commonly involving bursectomy, superomedial angle resection, or partial scapulectomy. High satisfaction rates of surgery were reported in VAS (6.9 ± 0.7 to 1.9 ± 0.9), American Shoulder and Elbow Surgeons scores (50.3 ± 12.2 to 80.6 ± 14.9), and mean simple shoulder test scores (5.6 ± 1.0 to 10.2 ± 1.1).Conclusion:Focused history and physical examination is the most crucial initial step in the diagnostic process, with supplemental imaging used to assess for structural etiologies when nonoperative management fails. Nonoperative management is as effective as surgical management in pain relief and is advised for 3 to 6 months before operative treatment.

Adult patient perceptions on the effectiveness of scoliosis specific exercises.

There is a paucity of research focusing on adults with scoliosis, yet many of these individuals suffer from pain and disability. Recent literature has demonstrated that for this patient population general physical therapy is no better than other non-operative treatment options.[1-3] This study assessed the perceptions of the effectiveness of Physiotherapeutic Scoliosis Specific Exercises (PSSE) on adult scoliosis. The purpose of this study is to present the results of a retrospective analysis of how adults with scoliosis perceive that physical therapy utilizing PSSE has impacted their quality of life (QoL), function, and pain. A 10 question survey was sent via a secure server (Qualtrics) to all PSSE participating patients ≥ 18 years old from one PSSE specialty clinic from the beginning of the PSSE program, 7 years. Survey responses were anonymous, collected by someone other than the primary investigator, and statistics were calculated with SPSS 24 (IBM Corp., Armonk, NY). Results: Fifty-seven adults (88.9% female) responded to the survey (55% response rate) with 67.2% being over the age of 55 years. The majority (61.9%) felt that PT had moderately or significantly positively impacted their QoL. The most common number of PT visits ranged from 5-10, after which 71.9% of participants were either somewhat or very confident in their ability to perform their PSSE program unsupervised at home. The most common frequency of home exercise program (HEP) performance was 1-2 times per week (46.0%) for a duration of 5-40 minutes. Quantitative analysis of exercise adherence using a Spearman's rho (rs) revealed positive associations between confidence in correctly performing the HEP with the perceived positive impact of the exercises (rs = .45, p < .001), the greater frequency of performing the HEP (rs = .30, p = .024) and greater time performing the HEP (rs = .33, p = .004). This retrospective analysis showed that 61.9% of adults with scoliosis felt that PT utilizing PSSE had moderately or significantly positively impacted their QoL. Adherence to a HEP is critical to the success of the program. Greater confidence in correctly performing the HEP was positively correlated with perceived impact, frequency and time spent exercising. The sample was limited to adults from one clinic that specializes in scoliosis and may not be generalizable to other clinics.

Treatment Strategies and Outcomes for Osteochondritis Dissecans of the Capitellum

Background: The optimum management of osteochondritis dissecans (OCD) of the capitellum is a widely debated subject. Purpose: To better understand the efficacy of different surgical modalities and nonoperative treatment of OCD as assessed by radiological and clinical outcomes and return to sports. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of all treatment studies published between January 1975 and June 2020 was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 76 clinical studies, including 1463 patients, were suitable for inclusion. Aggregate analysis and subgroup analysis of individual patient data were performed to compare the functional and radiographic outcomes between the various nonoperative and surgical treatment options for capitellar OCD. A unified grading system (UGS; grades 1-4) was developed from existing validated classification systems to allow a comparison of patients with similar-grade OCD lesions in different studies according to their treatment. Patient-level data were available for 352 patients. The primary outcome measures of interest were patient-reported functional outcome, range of motion (ROM), and return to sports after treatment. The influences of the capitellar physeal status, location of the lesion, and type of sports participation were also assessed. Each outcome measure was evaluated according to the grade of OCD and treatment method (debridement/microfracture, fragment fixation, osteochondral autograft transplantation [OATS], or nonoperative treatment). Results: No studies reported elbow scores or ROM for nonoperatively treated patients. All surgical modalities resulted in significantly increased postoperative ROM and elbow scores for stable (UGS grades 1 and 2) and unstable lesions (UGS grades 3 and 4). There was no significant difference in the magnitude of improvement or overall scores according to the type of surgery for stable or unstable lesions. Return to sports was superior with nonoperative treatment for stable lesions, whereas surgical treatment was superior for unstable lesions. Patients with an open capitellar physis had superior ROM for stable and unstable lesions, but there was no correlation with lesion location and the outcomes of OATS versus fragment fixation for high-grade lesions. Conclusion: Nonoperative treatment was similar in outcomes to surgical treatment for low-grade lesions, whereas surgical treatment was superior for higher grade lesions. There is currently insufficient evidence to support complex reconstructive techniques for high-grade lesions compared with microfracture/debridement alone.

The relationship between different dosages of mannitol 20% and osmolarity, blood sugar serum, and coagulation factors in moderate brain injury patients with increased intracranial pressure

ObjectiveTraumatic brain injuries have high mortality rates in many countries. Chemical parameters such as blood osmolarity, serum blood sugar, and coagulation factors can be used to assess the prognosis of a brain injury. Increased intracranial pressure and swelling of the brain are clinical manifestations of brain injury. One option for non-operative treatment is the use of mannitol (MT). This research aims to determine the dosage of MT 20% that demonstrates better levels of safety and effectiveness, based on the evaluation of 3 laboratory-test parameters. MethodThis research is a prospective cohort with a total sample of 30 patients with moderate brain injuries, who are divided randomly into two groups of different dosages of MT. ResultsThe results are analyzed using repeated measures ANOVA tests and are significant if p<0.05. We found differences in blood osmolarity, serum blood sugar, and coagulation factors between the two groups. A dosage of MT 20% 1g/kgBW has a higher value than a dosage of 0.5g/kgBW, but all were nonsignificant (p>0.05). ConclusionMT 20% does not affect blood osmolarity, serum blood sugar, and coagulation factors.

Cryoneurolysis for the management of chronic pain in patients with knee osteoarthritis; a double-blinded randomized controlled sham trial

ObjectivePain is the principal symptom in knee osteoarthritis (OA). Current non-operative treatment options have only moderate effects and often patients experience persistent pain or side-effects. Novel advances in the field of cryoneurolysis applies low temperatures to disrupt nerve signaling at the painful area, providing pain relief. The primary aim of this randomized controlled trial (RCT) is to investigate if cryoneurolysis is superior to sham at decreasing pain intensity 2 weeks after the intervention in patients with knee OA. Secondary aims are to explore effects on pain, quality of life and functional performance over 24 months.MethodsThis two-arm, parallel-group RCT, approved by the Regional Ethics Committee, will randomly allocate patients (n = 94) to a cryoneurolysis intervention group + standardized education and exercise (CRYO) or a sham group + standardized education and exercise (SHAM) (1:1 ratio). Both groups will be assessed at baseline, 2 weeks post intervention, post education and exercise and at 6, 12 and 24 months after cryoneurolysis. The primary outcome is the NRS knee pain intensity score assessed 2 weeks post the intervention. Secondary outcome measures include functional performance (chair-stand test, 40 m walk, stair test and maximum voluntary contraction of the knee), patient reported outcomes (quality of life (EQ5D), Knee and osteoarthritis outcome scores (KOOS), among others), use of analgesics, and adverse events over 24 months.Impact statementCryoneurolysis could potentially provide an effective, safe and non-pharmacological therapeutic option to treat pain in OA patients. The potential benefits include increased functional capacity and quality of life as a result of significant pain relief and improved benefits of physical exercise.Trial registrationClinicaltrials.gov, NCT03774121, registered 3 March 2018, http://www.clinicaltrials.gov

Surgical revascularization for Moyamoya disease in the United States: A cost-effectiveness analysis.

ObjectiveMoyamoya disease (MMD) is a vasculopathy of the internal carotid arteries with ischemic and hemorrhagic sequelae. Surgical revascularization confers upfront peri-procedural risk and costs in exchange for long-term protective benefit against hemorrhagic disease. The authors present a cost-effectiveness analysis (CEA) of surgical versus non-surgical management of MMD.MethodsA Markov Model was used to simulate a 41-year-old suffering a transient ischemic attack (TIA) secondary to MMD and now faced with operative versus nonoperative treatment options. Health utilities, costs, and outcome probabilities were obtained from the CEA registry and the published literature. The primary outcome was incremental cost-effectiveness ratio which compared the quality adjusted life years (QALYs) and costs of surgical and nonsurgical treatments. Base-case, one-way sensitivity, two-way sensitivity, and probabilistic sensitivity analyses were performed with a willingness to pay threshold of $50,000.ResultsThe base case model yielded 3.81 QALYs with a cost of $99,500 for surgery, and 3.76 QALYs with a cost of $106,500 for nonsurgical management. One-way sensitivity analysis demonstrated the greatest sensitivity in assumptions to cost of surgery and cost of admission for hemorrhagic stroke, and probabilities of stroke with no surgery, stroke after surgery, poor surgical outcome, and death after surgery. Probabilistic sensitivity analyses demonstrated that surgical revascularization was the cost-effective strategy in over 87.4% of simulations.ConclusionsConsidering both direct and indirect costs and the postoperative QALY, surgery is considerably more cost-effective than non-surgical management for adults with MMD.

Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review.

ContextPiriformis syndrome is a solely clinical diagnosis that often eludes the practitioner and goes underdiagnosed. PS is a pain syndrome and for those it affects, causes persistent pain and limits daily activity and work capacity. It is a form of deep gluteal syndrome that needs to be considered on the differential of low back pain as it comprises between 0.3% - 6% of all low back pain cases and is frequently underdiagnosed. Piriformis syndrome may be primary due anatomic anomalies or secondary, though the majority of cases are secondary to some insult. The objective of this manuscript is to provide a description of the epidemiology and presentation of piriformis as well as both non-operative and operative treatment options. We review all of the recent clinical evidence regarding the aforementioned therapies.Evidence AcquisitionLiterature searches were performed using the below MeSH Terms using Mendeley version 1.19.4. Search fields were varied until further searches revealed no new articles. All articles were screened by title and abstract. Decision was made to include an article based on its relevance and the list of final articles was approved three of the authors. This included reading the entirety of the article. Any question regarding the inclusion of an article was discussed by all authors until an agreement was reached.ResultsMedical management and physical therapy show some promise; however, when conservative treatment fails minimally invasive methods such as steroid injections, botulinum toxin injections, dry needling are all efficacious and there is substantial clinical evidence regarding these therapies. In those patients in which minimally invasive techniques do not result in an adequate relief of pain and return of function, endoscopic release can be considered. Endoscopic release is far superior to open release of the piriformis syndrome given the higher success and lower rate of complications.ConclusionsPiriformis syndrome is an important differential diagnosis in the work up of lower back pain and should not be ruled out with proper examination and testing. Clinicians should consider medical management and conservative management in the initial treatment plan for piriformis syndrome. There are many options within the conservative management and the literature shows much promise regarding these. Physical therapy, steroid injections, botulinum toxin injections, and dry needling are all potentially effective therapies with few adverse effects. Surgical options remain as gold standard, but only when conservative management has failed and the symptoms are significant to affect daily living activities. Endoscopic decompression of the sciatic nerve with or without release of the piriformis muscle has a reported high likelihood of success and a low complication rate. Current literature supports the preference of the endoscopic approach over the open approach due to improved outcomes and decreased complications. Further research is to well define the metrics for the diagnosis of piriformis syndrome and may include a need to develop diagnostic criteria.

Comparing Intra-articular Injections of Leukocyte-Poor Platelet-Rich Plasma Versus Low-Molecular Weight Hyaluronic Acid for the Treatment of Symptomatic Osteoarthritis of the Hip: A Double-Blind, Randomized Pilot Study.

Background:Hyaluronic acid (HA) and leukocyte-poor platelet-rich plasma (LP-PRP) are 2 nonoperative treatment options that have been studied in patients with hip osteoarthritis (OA).Purpose:To compare the efficacy of intra-articular injections of low–molecular weight (LMW) HA and LP-PRP in patients with hip OA.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:A total of 34 patients (36 hips) presenting with signs of hip OA were randomized to receive 3 blinded, weekly intra-articular injections of either LP-PRP or LMW-HA. Patients were prospectively evaluated before injections and at 6 weeks and then at 3, 6, 12, and 24 months. The primary outcome, conversion to total hip arthroplasty (THA) or a hip resurfacing procedure, was analyzed along with secondary outcomes including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and hip range of motion.Results:The final analysis included 33 hips (mean Kellgren-Lawrence grade, 2.73) (LMW-HA: n = 14; LP-PRP: n = 19) in 31 patients (18 male; mean age, 53.8 years). Significantly more patients converted to THA or a hip resurfacing procedure in the LMW-HA group (7/14; 50.0%) (mean, 1.3 years after first injection) than the LP-PRP group (3/19; 15.8%) (mean, 0.73 years after first injection) (P = .035). There was no significant improvement or decline in any outcome scores within the LMW-HA group from before injections to 6 weeks or 3, 6, and 12 months. For the LP-PRP group, WOMAC overall (P = .032), joint (P = .030), and function scores (P = .025) significantly improved from before injections to 6 weeks, and WOMAC joint scores significantly improved from before injections to 6 months (P = .036). When comparing the difference between groups in internal rotation at 90° of hip flexion from before injections to 6 months, the LP-PRP group demonstrated a mean 5.0° improvement, while the LMW-HA group showed a mean 1.5° decrease (P = .028).Conclusion:Intra-articular hip injections of LP-PRP in patients with hip OA resulted in an improvement in WOMAC scores and hip internal rotation at 6 months and delayed the need for THA or a hip resurfacing procedure compared with treatment with LMW-HA. A longer follow-up is necessary to further compare the effects of LP-PRP and LMW-HA injections in patients with hip OA.Registration:NCT01920152 (ClinicalTrials.gov identifier).

The Effectiveness of Alpha-2-Macroglobulin Injections for Osteoarthritis of the Knee

Osteoarthritis, a degenerative and debilitating joint disease, is one of the most prevalent diseases in the United States. Despite the significant burden osteoarthritis can place on an individual and society, nonoperative treatment options are still very limited. Little clinical data exists on the use of injectable macromolecules for the treatment of osteoarthritis of the knee. Alpha-2-macroglobulin (A2M), a naturally occurring macromolecule, inhibits the many endogenous and exogenous proteinases presenting in the pathogenesis of osteoarthritis. This macromolecule is not typically contained in high quantities in traditional PRP preparations. To date, no studies exist evaluating the effectiveness of A2M with other intra-articular injectables. The purpose of this study is to compare the clinical effectiveness of intra-articular injection of A2M against both platelet-rich plasma (PRP) and corticosteroids. This prospective randomized control trial was conducted at a single medical center. Seventy-five patients with symptomatic knee osteoarthritis with Kellgren-Lawrence grade 2 or 3 were randomized into one of three cohorts receiving intra-articular injection. One group was given PRP, one group was given A2M, and one group was given corticosteroids. All groups had blood drawn to simulate A2M preparation. Patient reported outcomes were collected prior to injection, 6 weeks and 12 weeks following injection. Several measures were used for clinical assessment including the visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm, and Tegner scores. Seventy-five patients with a mean age of 61.08 (± 8.48) were enrolled between June 2018 and February 2019. At six weeks, the A2M group had the greatest improvements in VAS (-1.60) and WOMAC (-10.9) scoring, however, the differences were not statistically significant. Between the injection and the twelve week visit, the A2M group had a statistically significant improvement in WOMAC score compared with traditional PRP (-18.43 vs -5.70, p <0.02). Overall, both corticosteroid (-1.57) and A2M (-1.70) had a better improvements in VAS when compared with traditional PRP (-0.61). However, these were also not statistically significant. Our study demonstrates Alpha 2 Macroglobulin shows similar effectiveness to corticosteroids in the treatment of knee osteoarthritis. Both A2M and corticosteroids appear to show better effectiveness than traditional PRP injection, however the differences are small and did not reach statistical significance in most outcome measures. The extra preparation time required and cost associated with A2M may not warrant its routine use in the management of knee osteoarthritis.

Intra-articular Injections of Cross-linked Hyaluronic Acid in Japanese Patients with Symptomatic Osteoarthritis of the Hip.

ABSTRACTObjectives:We investigated the efficacy and safety of Hylan G-F 20 for the treatment of hip osteoarthritis in Japanese patients.Methods:Twenty-nine patients with hip osteoarthritis (OA) received Hylan G-F 20 injection into the hip. The visual analog scale of pain during gait (VAS-G), VAS of pain at rest, hip joint function evaluated by the Japanese Orthopaedic Association (JOA) score, health-related quality of life (HRQoL), and adverse events were evaluated before, immediately after, and at 4, 8, and 12 weeks after injection. Patients were categorized according to the severity of OA (mild and severe OA groups) and dysplasia (dysplastic and non-dysplastic groups) and these groups were compared.Results:After the injection, VAS-G improved significantly for 12 weeks. VAS-G was lower (less pain) in the mild OA group than in the severe OA group at each time point. There were no differences in VAS-G between the dysplastic and non-dysplastic groups throughout the observation period. VAS-G improved significantly in the dysplastic group after the injection. The JOA score and HRQoL demonstrated the same tendency as VAS-G. Three patients experienced worsening of local pain immediately after the injection; however, the pain on the following day was less than that before the injection in all three hips.Conclusions:Hylan G-F 20 injection into the hip joint was effective in reducing hip pain and can be used as a non-operative treatment option for hip OA in the Japanese population.

Recurrence of Acute Right Colon Diverticulitis Following Nonoperative Management: A Systematic Review and Meta-analysis.

There are currently no guidelines on the management of right colon diverticulitis. Treatment options have been extrapolated from the management of left-sided diverticulitis. Gaining knowledge of the risk and morbidity of diverticulitis recurrence is integral to weighing the benefit of elective surgery for right-sided diverticulitis. The purpose of this study was to summarize the recurrence rate and the morbidity of recurrence of Hinchey classification I/II, right-sided diverticulitis following nonoperative management. PubMed, EMBASE, and Cochrane Database of Collected Reviews were searched up to June 2019. Observational cohort studies evaluating outcomes following nonoperative management were reviewed. No randomized controlled trials were available. Intravenous antibiotics with or without percutaneous drainage of associated abscess were administered. The primary outcomes measured were the recurrence rate and morbidity associated with recurrence. Two independent investigators extracted data. The rates of recurrence were pooled by using a random-effects model. There were 1584 adult participants from a total of 11 studies (9 retrospective cohort and 2 prospective cohort studies) included in the analysis. Over a median follow-up period of 34.2 months, the pooled recurrence rate was 12% (95% CI, 10%-15%). Twenty of 202 patients (9.9%) required urgent surgery at the time of first recurrence. There was no mortality. Subset analysis excluding 3 studies that included percutaneous drainage as a nonoperative treatment option did not change the recurrence rate (12% (95% CI, 9%-15%)) or heterogeneity. Funnel plot assessment revealed no publication bias. There were no randomized controlled trials available. The statistical heterogeneity was moderate (I = 46%). Nonoperative management of Hinchey I/II right-sided diverticulitis is safe and feasible. The recurrence rate is relatively low, and complications that require urgent operation are uncommon. CRD42019131673.

Anal Fissure in Children.

Anal fissure is a common clinical problem in children and is defined as a longitudinal tear in the anal canal. The typical presentation is painful defecation and rectal bleeding. The etiology of anal fissure is unknown, but passage of hard stools and increased internal anal sphincter pressure are considered important factors. The treatment is oriented to relieve the spasm of the internal anal sphincter, which prevents healing of the fissure. Conservative management with stool softeners, topical analgesics, and sitz baths is recommended as first-choice therapy. Surgical treatment has been replaced by nonoperative management as definitive therapy, which is associated with a marginally higher success rate than placebo. Most recent studies have focused on nonoperative treatment with glyceryl trinitrate, calcium channel blockers, or botulinum toxin injection treatment. There are a few controlled studies to compare the different nonoperative treatment options in children. Success rates vary between the studies, and there is no clear evidence about which is the optimal nonoperative treatment. A significant recurrence rate has been reported after nonoperative management of anal fissure. It is important to treat constipation to avoid recurrent tears in the anal canal.

Can the addition of ultrasound-guided genicular nerve block using 5% dextrose water augment the effect of autologous platelet rich plasma in treating elderly patients with knee osteoarthritis?

BackgroundTo investigate whether the addition of injecting 5% dextrose water to the genicular nerves can augment the effect of platelet rich plasma (PRP) injections in treating elderly patients with moderate degree of knee osteoarthritis (OA). MethodsForty-six elderly patients with grade 3 on the Kellgren and Lawrence knee OA grading system were divided into control and genicular nerve block groups. Both groups received 4 milliliters (mL) of PRP injected into the knee joint and 2 mL of PRP to the pes anserinus complex. In the nerve block group, 2 mL of 5% dextrose water was also injected to each genicular nerve. In the control group, normal saline was used to inject the genicular nerves. Proteomic technique of 2-dimensional electrophoresis was used to detect the changes in synovial fluid (SF) protein concentrations. Lequesne Functional Index was used to evaluate knee functional status. ResultsAfter 3 monthly PRP injections, concentrations of SF total protein, and proteins associated with inflammation decreased. Protein concentrations associated with chelation increased. In the nerve block group, improvements in pain and in the functional status of the knee joint lasted up to a period of 6 months. At 1 month and 3 months after the injections, Lequesne Functional Index was less than 7 (a value of 7 or higher indicates knee OA). ConclusionThe concept of combining 5% dextrose water injection to the genicular nerves, and PRP injection into the knee joint and to the pes anserinus complex can be a feasible non-operative conservative treatment option for elderly patients with knee OA.

YouTube – An unreliable source of information for Total hip replacement

BackgroundYouTube is now becoming important for people as a source of health related information. The aim of the present study was to assess the educational quality of YouTube videos related to Total hip replacement. MethodsA search on YouTube for the term “Total hip replacement” was performed. Data from 47 most relevant videos were collected. Quality assessment checklists with a scale of 0–10 points were developed to evaluate the video content. Videos were grouped into poor quality (grade 0–3), acceptable quality (grade 4–7), and excellent quality (grade 8–10). Results91% of videos were of poor educational quality (43/47), 9% were of acceptable quality (4/47) and none of the videos were of excellent quality. Common missing information was regarding non-operative treatment options and types of bearing surfaces. ConclusionsVideos regarding total hip replacement are frequently viewed on YouTube which is an unreliable educational source for patients, so it is important that surgeons should have knowledge about the available content so as to direct our patients to a suitable source. Also, surgeons should upload more informative videos that can be understood by patients which will be beneficial in providing information and education regarding Total Hip Replacement.

Alpha-2-Macroglobulin Not Significantly Better Than Regular PRP For Knee Arthritis Symptoms

Objectives:Osteoarthritis, a degenerative and debilitating joint disease, is one of the most prevalent diseases in the United States. Despite the significant burden osteoarthritis can place on an individual and society, nonoperative treatment options are still very limited. Little clinical data exists on the use of injectable macromolecules for the treatment of osteoarthritis of the knee. Alpha-2-macroglobulin (A2M), a naturally occurring macromolecule, inhibits the many endogenous and exogenous proteinases presenting in the pathogenesis of osteoarthritis. To date, no studies exist evaluating the effectiveness of A2M with other intra-articular injectables. The purpose of this study is to compare the clinical effectiveness of intra-articular injection of A2M against both platelet-rich plasma (PRP) and corticosteroids.Methods:This prospective randomized control trial was conducted at a single medical center. Seventy-five patients with symptomatic knee osteoarthritis with Kellgren-Lawrence grade 2 or 3 were randomized into one of three cohorts receiving intra-articular injection. One group was given PRP, one group was given A2M, and one group was given corticosteroids. All groups had blood drawn to simulate A2M preparation. Patient reported outcomes were collected prior to injection, 6 weeks and 12 weeks following injection. Several measures were used for clinical assessment including the visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm, and Tegner scores.Results:Seventy-five patients with a mean age of 61.08 (± 8.48) were enrolled between June 2018 and February 2019. At six weeks, the A2M group had the greatest decrease in VAS (-1.60) and WOMAC (-10.9), however, the differences were not statistically significant. Between the injection and the twelve week visit, the A2M group had a statistically significant difference in WOMAC score compared with PRP (-18.43 vs -5.70, p <0.02). Overall, both corticosteroid (-1.57) and A2M (-1.70) had a similar improvement in VAS when compared with PRP (-0.61). These differences were also not statistically significant.Conclusions:Our study demonstrates Alpha 2 Macroglobulin shows similar effectiveness to corticosteroids in the treatment of knee osteoarthritis. Both A2M and corticosteroids appear to show marginally better effectiveness than PRP injection, however the differences are small and did not reach statistical significance in most outcome measures.

Transitional fracture of the distal radius: a rare injury in adolescent athletes. Case series and literature review

BackgroundTransitional fractures are fractures in adolescents where partial closure of the epiphyseal growth plate has occurred. These fractures are most commonly reported in the distal tibia. With respect to the distal radius, only a few case reports describing transitional fractures exist. Furthermore, relatively little is known about epiphyseal closure of the distal radius. A case series of four transitional fractures of the distal radius is presented by comparing non-operative and operative treatment options. At present, this is the largest case series in the literature dealing with this rare injury.Case presentationWe present three cases of four transitional fractures of the distal radius including 1–year follow-up. Patient age ranged from 16 to 18 years including a gender ratio of two males to one female. Clinical and radiographic assessments took place 6 and 12 weeks and 1 year after trauma/surgery. Three transitional fractures were treated with open reduction and internal volar plate fixation followed by functional rehabilitation. One transitional fracture was treated non-operatively. All cases showed an excellent functional outcome.ConclusionsThe primary treatment goal in transitional fractures is anatomic reduction of the articular surface. Non-operative treatment of transitional fractures of the distal radius is the most commonly reported treatment option. Additionally, different fixation options have been described, including the use of Kirschner wires (K-wires) and lag screws. The presented cases demonstrate that volar plate fixation followed by functional rehabilitation is a valuable treatment option in significantly displaced transitional fractures of the distal radius. Furthermore, we discuss the pathogenesis as well as the different treatment options by critical reviewing the literature.