Nonoperative Treatment Strategies Research Articles

Ultrasonographic measurements of gastro-soleus fascia thickness in midportion Achilles tendinopathy: A case-control study

BackgroundThe Achilles tendon is one of the thickest, largest, and strongest tendons in the human body. Biomechanically, the AT represents the conjoint tendon of the triceps surae muscle, placed in series with the plantar fascia (PF) to ensure force transmission from the triceps surae toward the toes during walking, running, and jumping. Commonly encountered in the diagnostic evaluation of heel pain, Achilles tendinopathy (AT) refers to a combination of pathological changes affecting the tendon itself often resulting from excessive repetitive stress and overuse. Nevertheless, increasing evidence demonstrates that structural alterations due to overuse or abnormal patterns of skeletal muscle activity are not necessarily restricted to the muscles or tendons but can also affect the fascial tissue. At the same time, there has been recent discussion regarding the role of the fascial tissue as a potential contributor to the pathophysiological mechanisms of the development of several musculoskeletal disorders including tendinopathies. To the best of our knowledge, ultrasound (US) imaging studies on the fascial structures related to the triceps surae complex, as well as their possible correlation with Achillodynia have never been presented in the current literature. MethodsIn the present study, a comparative US imaging evaluation of textural features of the suro-Achilleo-plantar complex was performed in 14 healthy controls and 14 symptomatic subjects complaining of midportion AT. The thickness of the Achilles tendon, paratenon, intermuscular fascia, and PF has been assessed with US. In addition, both groups underwent the Victorian Institute of Sport Assessment-Achilles (VISA-A), a disease-specific questionnaire that measures the severity of symptoms of AT. Correlations between quantitative ultrasound measures and VISA-A scores were determined through Pearson or Spearman's rho correlations. ResultsOur ultrasonographic findings revealed statistically significant differences (p<0.05) in Achilles tendon and paratenon thicknesses between AT patients and controls. No significant differences were observed between groups in PF at the calcaneal insertion as all mean measures were within the expected range of a normal PF on US imaging. In contrast, in tendinopathic subjects, the deep intermuscular fascia between medial gastrocnemius (MG) and soleus (SOL) muscles is significantly (p<0.01) and considerably thickened compared to those of healthy subjects. Moderate correlations exist between tendon and paratenon thicknesses (r= 0.54, p= 0.04) and between MG-SOL fascia and tendon thicknesses (r= 0.58, p= 0.03). Regarding symptom severity and US morphological findings, the Spearman ρ test showed no correlation. ConclusionsOur data demonstrate that, in symptomatic subjects, US alterations are not restricted to paratenon and intratendinous areas, but also affect upstream structures along the myofascial chain, resulting in thickening of the fascia interposed between MG and SOL muscles. Moreover, positive correlations were found between MG-SOL fascia thickening and abnormalities in AT, paratenon, and symptom severity. Thus, US alterations in the fascial system should be interpreted within the clinical context of patients with AT as they may in turn represent important predictors of subsequent clinical outcomes and could help healthcare professionals and clinicians to refine non-operative treatment strategies and rehabilitation protocols for this disease.

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.

Cell Sheet Technology: An Emerging Approach for Tendon and Ligament Tissue Engineering.

Tendon and ligament injuries account for a substantial proportion of disorders in the musculoskeletal system. While non-operative and operative treatment strategies have advanced, the restoration of native tendon and ligament structures after injury is still challenging due to its innate limited regenerative ability. Cell sheet technology is an innovative tool for tissue fabrication and cell transplantation in regenerative medicine. In this review, we first summarize different harvesting procedures and advantages of cell sheet technology, which preserves intact cell-to-cell connections and extracellular matrix. We then describe the recent progress of cell sheet technology from preclinical studies, focusing on the application of stem cell-derived sheets in treating tendon and ligament injuries, as well as highlighting its effects on mitigating inflammation and promoting tendon/graft-bone interface healing. Finally, we discuss several prerequisites for future clinical translation including the selection of appropriate cell source, optimization of preparation process, establishment of suitable animal model, and the fabrication of vascularized complex tissue. We believe this review could potentially provoke new ideas and drive the development of more functional biomimetic tissues using cell sheet technology to meet the needs of clinical patients.

Do the fasciae of the soleus have a role in plantar fasciitis?

Plantar fasciitis is a chronic, self-limiting, and painful disabling condition affecting the inferomedial aspect of the heel, usually extending toward the metatarsophalangeal joints. There is compelling evidence for a strong correlation between Achilles tendon (AT) loading and plantar aponeurosis (PA) tension. In line with this, tightness of the AT is found in almost 80% of patients affected by plantar fasciitis. A positive correlation has also been reported between gastrocnemius-soleus tightness and heel pain severity in this condition. Despite its high prevalence, the exact etiology and pathological mechanisms underlying plantar heel pain remain unclear. Therefore, the aim of the present paper is to discuss the anatomical and biomechanical substrates of plantar fasciitis with special emphasis on the emerging, though largely neglected, fascial system. In particular, the relationship between the fascia, triceps surae muscle, AT, and PA will be analyzed. We then proceed to discuss how structural and biomechanical alterations of the muscle-tendon-fascia complex due to muscle overuse or injury can create the conditions for the onset of PA pathology. A deeper knowledge of the possible molecular mechanisms underpinning changes in the mechanical properties of the fascial system in response to altered loading and/or muscle contraction could help healthcare professionals and clinicians refine nonoperative treatment strategies and rehabilitation protocols for plantar fasciitis.

Pathophysiology of Medication-Related Osteonecrosis of the Jaw-A Minireview.

Medication-related osteonecrosis of the jaw (MRONJ) is a rare but serious adverse effect of antiresorptive medications administered for control of osseous malignancy, osteoporosis, or other bone metabolic diseases. Despite being reported in the literature two decades ago, MRONJ etiology, pathophysiology, and progression remain largely unknown, and current nonoperative or operative treatment strategies are mostly empirical. Several hypotheses that attempt to explain the mechanisms of MRONJ pathogenesis have been proposed. However, none of these hypotheses alone is able to capture the complex mechanistic underpinnings of the disease. In this minireview, we aim to highlight key findings from clinical and translational studies and propose a unifying model for the pathogenesis and progression of MRONJ. We also identify aspects of the disease process that require further investigation and suggest areas for future research efforts toward calibrating methodologic approaches and validating experimental findings. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Association between the plantar fasciitis and isolated contracture of gastrocnemius in Lahore

Background: Plantar fasciitis, reportedly the most common cause of pain in the inferior heel, is estimated to account for 11 to 15 percent of all foot symptoms requiring professional care among adults. Objective: The objective is to determine the Association between the plantar Fasciitis and Isolated Contracture of Gastrocnemius. Methods: It was the cross-sectional study; convenient sampling technique was used to collect data. Study was completed within four months after the approval of synopsis. Sample size was 168. Participants was selected based on inclusion and exclusion criteria. Self-made questionnaire used for this study. Silfverskiold test was used for isolated contractures of gastrocnemius. Data was analyzed by SPSS. Results: The mean age of the respondents was 39.4 years with SD value of 3.74. in this study, there was 32.1% was male and 67.9% were female respondents which showed that planter fasciitis is more common among female that males. The p value less than 0.05 indicate that there is a positive association between the limitation of range of ankle dorsiflexion and duration or planter fasciitis (acute or chronic). 41.1% of the participants with acute planter fasciitis and 58.9 with chronic planter fasciitis. Conclusion: Limitation in the dorsiflexion of ankle is mostly linked with the planter fasciitis. In current study, it was concluded that more than half of the patients with planter fasciitis had isolate gastrocnemius contracture. The findings of current work can be applied to develop and further refine non-operative and operative treatment strategies for those with recalcitrant plantar fasciitis. Key Words: Planter fasciitis, Contracture, Flat foot

In-Season Management of Shoulder Instability: How to Evaluate, Treat, and Safely Return to Sport.

Anterior glenohumeral instability is a common injury in contact and collision athletes, and in-season management remains a controversial topic. Several recent studies have examined non-operative and operative management of in-season athletes after instability events. Non-operative treatment is associated with faster return to play and higher rates of recurrent instability. Dislocations and subluxations have similar rates of recurrent instability but non-operatively treated subluxations have a quicker return to play than dislocations. Operative treatment is often a season ending decision but is associated with high rates of return to sport and significantly lower rates of recurrent instability. Indications for in-season operative intervention may include critical glenoid bone loss (>15%), an off-track Hill-Sachs lesion, an acutely reparable bony Bankart lesion, high-risk soft tissue injures such as a humeral avulsion of the glenohumeral ligament or displaced anterior labral periosteal sleeve avulsion, recurrent instability, insufficient time remaining in season to rehabilitate from injury, and inability to successfully return to sport with rehabilitation. It is the role of the team physician to appropriately educate athletes on risks and benefits of operative and non-operative treatment strategies and guide athletes through the shared decision-making process that balances these risks against their long-term health and athletic career goals.

Post COVID community based self-care management of disabling osteoarthritis: importance and possible targeted needs

Background: Osteoarthritis, a highly common, disabling joint disease affecting a large number of older adults is presently incurable, and not always amenable to surgery or pharmacologic interventions. Purpose: Further complicated by multiple past and ongoing COVID-19 pandemic issues and disease consequences, the purpose was to examine what current data reveal as to the prevailing epidemiological features of osteoarthritis and its pathology. Another was to review the utility of some non-pharmacological and non-operative treatment strategies that have been advocated for alleviating the pain and disability of this disease in later life. Methods: Building on a 35 year prior review conducted in 2015, this current review was conducted to identify relevant literature published on this topic over the last 5 years, particularly since COVID-19 onset in 2019. Key words included osteoarthritis, COVID-19, prevention, and intervention. Results: As in prior years, osteoarthritis continues to induce considerable physical disability and consistently impedes the attainment of a high life quality for many older adults. Although not studied to any degree, COVID-19 factors may be expected to render further challenges that compound the disease presentation and its mitigation over time, especially among the long COVID affected older adult. In the face of closures, limited resources, and complex disease presentations, it does appear a variety of non-operative and non-pharmacologic approaches may yet influence the disease process and functional outcomes more positively than not with low safety risks. They may help the older adult more effectively even if surgery is indicated and multiple medications are yet required. Conclusion: The application of one or more carefully designed conservative interventions is likely to reduce the functional disability and pain experienced by older people with any form of osteoarthritis, regardless of whether surgical and or pharmacologic strategies are indicated.

Success Rate of Non-Operative Treatment of Insertional Achilles Tendinopathy

Category: Other Introduction/Purpose: Non-operative treatment of Insertional Achilles tendinopathy (IAT) is historically thought to be effective in 50-70% of cases, the success rate of modern non-operative treatment is not well defined in the current literature. The purpose of this study is to define the success rate of modern non-operative treatment of IAT. Methods: A retrospective chart review was performed to identify 133 patients (137 ankles) who received either surgical or non- surgical treatment of IAT at an academic medical center between September 2015 and June 2019. The success rates of various non-operative treatment strategies were recorded in order to determine which, if any, had the highest success rate. Patient factors including demographic factors, comorbidities, modifiable risk factors, patient-reported outcome measures (PROMs), physical exam findings, and radiographic parameters were recorded to determine those that are associated with the failure of conservative management of IAT. Results: The overall success rate of non-operative treatment was 82.5% and the average time from initial diagnosis to surgery was 198.83 (range, 28-486) days. There was no difference in treatment method between those successfully treated conservatively and those who went on to require surgery. At first encounter, patients who later received surgery were significantly more likely to be female (91.7% vs. 66.4%; p=.013) and have higher VAS pain scores (6.54 vs. 5.10; p=.045), lower SF-12 physical scores (25.16 vs. 35.61; p&lt;.001), hypertension (79.2% vs. 52.2%; p=.015), Haglund's Deformity on physical exam (95.7% vs. 71.3%; p=.014), and greater cross-sectional tendon disease involvement on MRI (43.5% vs. 28.0%; p=.001). (Table 1) Conclusion: The success rates of non-operative treatment for IAT may be higher than historical reports, at just over 80%. Several patient factors were shown to be associated with the failure of conservative management of IAT. Orthopaedic surgeons should use this information to provide more accurate patient-specific counseling on the most appropriate treatment strategies for IAT.

ACLD patients exhibit additional knee kinematic asymmetries at the speed level of healthy subjects.

Anterior cruciate ligament deficiency (ACLD) patients tend to walk slowly but try to catch up with the speed level of healthy subjects daily. Exploring the effects of the walking speed level of healthy subjects on the ACLD patients’ knee kinematics is important to improving non-operative treatments and delaying the progression of posttraumatic knee osteoarthritis. This study aimed to explore whether healthy controls’ walking speed level leads to additional knee kinematic asymmetries in patients with ACLD. 27 ACLD patients and 29 healthy controls were recruited for the study. The ACLD patients walked at two levels of walking speed, including self-selected and healthy controls’ walking speed levels. A three-dimensional gait analysis system was used to collect their knee kinematic data. ACLD patients exhibited more kinematic asymmetries when walking at healthy controls’ walking speed level than at their self-selected speeds. The kinematic asymmetries included increased posterior tibial translation (4.6 mm) and anteroposterior tibial ROM (3.9 mm), abduction angle (1.5°), and distal tibial translation (3.2 mm) asymmetries (p < 0.05). Our findings are meaningful for developing non-operative treatment strategies for patients with ACLD. To get fewer knee kinematic asymmetries, self-selected walking speed could be suggested for patients with ACLD daily rather than the speed levels of healthy subjects.

Inflatable penile prosthesis infection successfully managed by non-operative novel treatment strategies: A case report

ABSTRACT Introduction IPP infections occur in approximately 1% of cases. The fundamental principle for treatment has always been surgical removal of all components. Explantation/reimplantation surgery, however, may be unsuccessful, require additional surgeries, and/or result in poor patient satisfaction, reduced penile sensation, and decreased penile length. A patient presented 4 weeks post-op with an obvious IPP infection. Culture of scrotal drainage prior to antibiotic administration grew serratia marcescens, enterococcus faecalis, and citrobacter freundii. The patient was informed explanation was required, but he refused and requested we “do what we can” first. He was made aware of the lack of data supporting non-operative strategies for IPP infection. Objective To present, likely for the first time, non-operative strategies including IV/oral antibiotics, low intensity shockwave therapy (LiSWT), and immune therapy can result in successful IPP infection treatment. Methods A 49 yo with a 14 year history of ED underwent insertion of an 20 cm Titan IPP (Coloplast) with submuscular reservoir placement. Four weeks post-op he presented with fever (101°F), elevated WBC (15,400), purulent drainage from a swollen, tender scrotum, and tenderness of all IPP components. We discussed non-operative management. He was admitted for broad spectrum IV antibiotics/antifungal agents: Vancomycin, Piperacillin and Tazobactam, and Fluconazole. After 6 days of IV antibiotics the patient became afebrile, WBC normalized (8,000) but he developed mildly abnormal renal and liver function tests. He was discharged on oral Levofloxacin daily for 30 days. Grayscale ultrasound showed fluid around the pump and scrotal tubing with significant device tenderness and scrotal drainage through two small sinus tracts confirming persistent infection. We assessed the degree of purulent scrotal drainage on gauze kept on the scrotum for 10 hour periods. LiSWT (Urogold 100 MTS, parabolic unfocused probe OPP 155, energy flux density 0.13 mJ/mm2, Hz 3.0, total shocks 6,600/treatment) was administered to the device components and scrotum for two weeks daily, then twice weekly x 2 weeks and then weekly x 4 weeks. Concomitantly he received immune therapy via subcutaneous peptide administration and ozone blood dialysis twice weekly x2 weeks and then weekly x 4 weeks. Results The patient progressively improved, remaining afebrile, with WBC (5,000) and liver and renal function tests normalized at 1 week. Scrotal drainage stopped at 2 weeks and scrotal sinus tracts healed. There was no pain/tenderness of device components or scrotum at 2.5 weeks. There was no skin fixation to any device component. The patient could easily inflate/deflate the device to full rigidity/flaccidity without pain at 3 weeks and intercourse with orgasm at 5 weeks. Grayscale ultrasound at 4 weeks showed absent fluid around the device components. Conclusions This is the first case report of successful management of an infected IPP using non-operative novel treatments. The effect of immune therapy is to enhance immune response to infection. Concerning the management of infection with LiSWT, it has been shown to have anti-infective properties, upregulate/recruit anti-bacterial/microbial peptide LL37, increase local blood flow, possibly inhibit biofilm, and result in salvage of infected breast and hip prostheses. Disclosure Work supported by industry: no.

The management of traumatic shoulder instability

The broad range of movement of the glenohumeral joint means that anatomical or traumatic aberrations can predispose the shoulder to instability and dislocations. This pathology predominantly affects young patients, especially males, partaking in contact sports and those with hyperlaxity. Both non-operative and operative treatment strategies aim to reduce further instability episodes, which have been shown to predispose patients to early osteoarthritis. A number of patient-related and anatomical factors need to be taken into consideration when deciding between the various available management strategies, which each have their own potential complications, predisposition to recurrent dislocation and technical profiles. The degree of humeral and glenoid bone loss is a key factor in increasing the likelihood of recurrent dislocation and can therefore influence whether surgery is undertaken, or if the bone loss needs to be addressed in addition to soft tissue stabilization.

Preoperative radiotherapy for rectal cancer: A bibliometric analysis of the 100 most-cited research articles.

Preoperative long-course radio-chemotherapy (LC-RCHT) or preoperative short-course radiotherapy (SC-RT) are widely used in the treatment of locally advanced rectal cancer (LARC). This study aimed to evaluate the 100 most-cited research articles focused on preoperative radiotherapy for rectal cancer to reveal existing academic trends and the direction of therapeutic research. This was a retrospective study based on publicly accessible data. The Web of Science database was used to identify the 100 most-cited articles. The median values for total citation and average citation per year (CPY) were 240.50 (range, 150-3787) and 17.32 (5.03-222.76), respectively. Randomized (median: 24.88 vs 13.32, P = 0.001) and funded (median: 27.33 vs 14.73, P = 0.002) studies had more CPY than those with opposite characteristics. No significant difference was found between studies using SC-RT and LC-RCHT, in terms of average CPY (median: 15.27 for SC-RT vs 18.36 for LC-RCHT, P = 0.303). In terms of the primary aim of the investigation, studies investigating non-operative treatment strategies had higher CPY than those investigating other subcategories (p = 0.029). Randomized studies, funded studies, and studies investigating non-operative treatment were associated with more CPY. There remains equal interest in preoperative SC-RT and LC-RCHT for rectal cancer.

Exome and Tissue-Associated Microbiota as Predictive Markers of Response to Neoadjuvant Treatment in Locally Advanced Rectal Cancer.

The clinical and pathological responses to multimodal neoadjuvant therapy in locally advanced rectal cancers (LARCs) remain unpredictable, and robust biomarkers are still lacking. Recent studies have shown that tumors present somatic molecular alterations related to better treatment response, and it is also clear that tumor-associated bacteria are modulators of chemotherapy and immunotherapy efficacy, therefore having implications for long-term survivorship and a good potential as the biomarkers of outcome. Here, we performed whole exome sequencing and 16S ribosomal RNA (rRNA) amplicon sequencing from 44 pre-treatment LARC biopsies from Argentinian and Brazilian patients, treated with neoadjuvant chemoradiotherapy or total neoadjuvant treatment, searching for predictive biomarkers of response (responders, n = 17; non-responders, n = 27). In general, the somatic landscape of LARC was not capable to predict a response; however, a significant enrichment in mutational signature SBS5 was observed in non-responders (p = 0.0021), as well as the co-occurrence of APC and FAT4 mutations (p < 0.05). Microbiota studies revealed a similar alpha and beta diversity of bacteria between response groups. Yet, the linear discriminant analysis (LDA) of effect size indicated an enrichment of Hungatella, Flavonifractor, and Methanosphaera (LDA score ≥3) in the pre-treatment biopsies of responders, while non-responders had a higher abundance of Enhydrobacter, Paraprevotella (LDA score ≥3) and Finegoldia (LDA score ≥4). Altogether, the evaluation of these biomarkers in pre-treatment biopsies could eventually predict a neoadjuvant treatment response, while in post-treatment samples, it could help in guiding non-operative treatment strategies.

Pain catastrophising, body mass index and depressive symptoms are associated with pain severity in tertiary referral orthopaedic foot/ankle patients.

IntroductionPatients with chronic foot/ankle pain are often referred for orthopaedic assessment. Psychological vulnerabilities influence pain states (including foot and ankle), therefore this study aimed to establish the prevalence and relative importance of compromised psychological health to perceived foot/ankle pain severity in people referred to an orthopaedic foot and ankle clinic with non-urgent presentations.MethodsPatients with triaged non-urgent foot/ankle referrals to the Department of Orthopaedics at Gold Coast University Hospital were recruited over a 12-month period and completed the Manchester-Oxford Foot and Ankle Questionnaire which was the primary measure. Participants also completed questionnaires assessing their anthropometric, demographic and health characteristics (Self-Administered Comorbidity Questionnaire) as well as measures of health-related quality of life (EuroQol-5-Dimensions-5-Level Questionnaire and EQ Visual Analogue Scale) and psychological health (Center for Epidemiological Studies-Depression scale, Pain Catastrophizing Scale and Central Sensitization Inventory). Descriptive statistics were used to summarise participant characteristics and a hierarchical multiple linear regression was employed to establish the extent to which psychological variables explain additional variance in foot/ankle pain severity beyond the effects of participant characteristics (age, sex, body mass index (BMI)).ResultsOne hundred and seventy-two adults were recruited ((64.0% female), median (IQR) age 60.9 (17.7) years and BMI 27.6 (7.5) kg/m2). Specific psychological comorbidities were prevalent including depressive symptoms (48%), central sensitisation (38%) and pain catastrophising (24%). Age, sex and BMI accounted for 11.7% of the variance in MOXFQ-index and psychological variables accounted for an additional 28.2%. Pain catastrophising was the most significant independent predictor of foot/ankle pain severity (accounting for 14.4% of variance), followed by BMI (10.7%) and depressive symptoms (2.3%).ConclusionsThis study demonstrated that specific psychological comorbidities and increased BMI are common in this cohort and that these factors are associated with the symptoms for which patients are seeking orthopaedic assessment. This knowledge should prompt clinicians to routinely consider the psychosocial components of patient presentations and develop non-operative and pre-operative treatment strategies which consider these factors with the goal of improving overall patient outcomes.

Degenerative Cervical Myelopathy: Towards a Personalized Approach.

Degenerative cervical myelopathy (DCM) is a recently coined term encompassing a variety of age-related and genetically associated pathologies, including cervical spondylotic myelopathy, degenerative disc disease, and ligamentous aberrations such as ossification of the posterior longitudinal ligament. All of these pathologies produce chronic compression of the spinal cord causing a clinical syndrome characterized by decreased hand dexterity, gait imbalance, and potential genitourinary or sensorimotor disturbances. Substantial variability in the underlying etiology of DCM and its natural history has generated heterogeneity in practice patterns. Ongoing debates in DCM management most commonly center around clinical decision-making, timing of intervention, and the ideal surgical approach. Pivotal basic science studies during the past two decades have deepened our understanding of the pathophysiologic mechanisms surrounding DCM. Growing knowledge of the key pathophysiologic processes will help us tailor personalized approaches in an increasingly heterogeneous patient population. This article focuses on summarizing the most exciting approaches in personalizing DCM patient treatments including biomarkers, factors affecting clinical decision-making, and choice of the optimal surgical approach. Throughout we provide a concise review on the conditions encompassing DCM and discuss the underlying pathophysiology of chronic spinal cord compression. We also provide an overview on clinical-radiologic diagnostic modalities as well as operative and nonoperative treatment strategies, thereby addressing knowledge gaps and controversies in the field of DCM.

APKASS Consensus Statement on Chronic Syndesmosis Injury, Part 1: Clinical Manifestation, Radiologic Examination, Diagnosis Criteria, Classification, and Nonoperative Treatment.

Background:Clinical manifestation, radiologic examination, diagnostic criteria, classification, and nonoperative treatment strategies regarding chronic syndesmosis injury remain unclear.Purpose:An international group of experts representing the fields of sports injuries in the foot and ankle area were invited to collaboratively advance toward consensus opinions based on the best available evidence regarding chronic syndesmosis injuries. All were members of the Asia-Pacific Knee, Arthroscopy and Sports Medicine Society (APKASS).Study Design:Consensus statement.Methods:From November to December 2020, a total of 111 international experts on sports medicine or ankle surgery participated in a 2-stage Delphi process that included an anonymous online survey and an online meeting. A total of 13 items with 38 statements were drafted by 13 core authors. Of these, 4 items with 15 clinical questions and statements were related to the clinical manifestation, radiologic examination, diagnostic criteria, classification, and nonoperative treatment strategies for chronic syndesmosis injury and are presented here. Each statement was individually presented and discussed, followed by a general vote. The strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.Results:Of the 15 questions and statements, 5 reached unanimous support and 10 achieved strong consensus.Conclusion:This APKASS consensus statement, developed by international experts in the field, will assist surgeons and physical therapists with diagnosis, classification, and nonoperative treatment strategies for chronic syndesmosis injury.

Comparative Efficacy of Nonoperative Treatments for Greater Trochanteric Pain Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.

An evolved understanding of the pathophysiology of greater trochanteric pain syndrome has led to a number of proposed nonoperative management strategies. The objective of this review was to compare the efficacy of the various nonoperative treatments for greater trochanteric pain syndrome (GTPS). Systematic review and network meta-analysis. PubMed, Embase, CENTRAL, SCOPUS, and Web of Science were searched to January 2020. Patients undergoing nonoperative treatment for GTPS. Nonoperative treatment strategies for GTPS including injections of corticosteroids, platelet-rich plasma, hyaluronic acid, dry needling, and structured exercise programs and extracorporeal shockwave therapy. Pain and functional outcomes. Bayesian random-effects model was performed to assess the direct and indirect comparison of all treatment options. Thirteen randomized controlled trials and 1034 patients were included. For pain scores at 1 to 3 months follow-up, both platelet-rich plasma (PRP) and shockwave therapy demonstrated significantly better pain scores compared with the no treatment control group with PRP having the highest probability of being the best treatment at both 1 to 3 months and 6 to 12 months. No proposed therapies significantly outperformed the no treatment control group for pain scores at 6 to 12 months. Structured exercise had the highest probability of being the best treatment for improvements in functional outcomes and was the only treatment that significantly improved functional outcome scores compared with the no treatment arm at 1 to 3 months. Current evidence suggests that PRP and shockwave therapy may provide short-term (1-3 months) pain relief, and structured exercise leads to short-term (1-3 months) improvements in functional outcomes.

Does a Multidisciplinary Triage Pathway Facilitate Better Outcomes After Spine Surgery?

Single-center prospective non-randomized matched cohort comparison. To compare elective lumbar spine surgery outcomes for cases triaged through a multidisciplinary spine pathway versus conventional referral processes. Many health care systems have facilitated low back pain (LBP) guidelines into primary care practice by creating local or regional "pathways" with the goal of enhanced quality of care, improved patient satisfaction and optimal resource utilization, particularly for imaging and surgery. Few comparative outcomes exist for LBP pathways, particularly for surgical outcomes. One-hundred-fifty patients (SSP group n = 75; conventional group n = 75) undergoing elective lumbar surgery for degenerative conditions between 2011 and 2016 were analyzed with 1-year follow-up. Patient self-reported outcomes included the Oswestry disability index (ODI), visual analogue pain scores (VAS) for back and leg, and EuroQol Group 5-Dimension self-report (EQ-5D). We also assessed baseline clinical features, indications for surgery, therapies received prior to surgery, type of surgery, wait times, and overall patient satisfaction. The groups had equivalent baseline demographics, body mass index, Saskatchewan Spine Pathway (SSP) classification of pain pattern, pain scores, functional scores, quality of life scores, indication for surgery, and type of surgery (instrumented or non-instrumented). There was no difference with respect to wait times to see the surgeon or for surgery. Wait time for magnetic resonance imaging (MRI) was significantly shorter for the SSP group (16.8 vs. 63.0 days, P < 0.001). Patients triaged through the SSP were significantly more likely to utilize multiple nonoperative treatment strategies prior to seeing the surgeon (P < 0.04). Patient satisfaction was significantly higher for SSP patients prior to surgical assessment (P = 0.03) but did not differ between groups after surgery. The SSP facilitates significantly shorter wait times for MRI and promotes nonoperative treatment strategies. Preoperative patient satisfaction is significantly higher among SSP patients, but there were no significant differences in surgical outcomes.Level of Evidence: 3.

Nonsurgical Management of Cartilage Defects of the Knee: Who, When, Why, and How?

The nonoperative practitioner managing individuals with cartilage defects should use a patient-centered, multifaceted approach that aims to individualize treatment to provide optimal benefit. These include addressing modifiable risk factors for disease progression and instituting interventions such as weight loss, nutrition, physical activity, and potentially regenerative medicine strategies. This review will focus on these nonoperative treatment strategies with a focus on when treatments are necessary, who will benefit from these approaches, why they are specifically appropriate, and, finally, how these treatments directly modify the structure of a patient's cartilage and resulting symptoms.