Successful Conservative Treatment Research Articles

Predictive factors for recurrent acute appendicitis after conservative treatment

Introduction Conservative treatment of acute appendicitis is gaining popularity, and identifying patients with a higher risk of recurrence is becoming increasingly important. Previous studies have suggested that older age, male sex, diabetes, appendicolith and abscess formation may be contributing factors, however, results from the adult population are inconsistent. Aim This study aims to identify predictive factors for recurrent appendicitis after conservative treatment. Methods This retrospective study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and follow-up data were retrieved from medical charts and radiologic images. Uni -and multivariable logistic regression analysis were performed using Stata Statistical Software. Results In total, 379 patients with conservatively treated acute appendicitis were identified, of which 78 (20.6%) had recurrence. All patients were followed-up for a minimum of 41 months after the first diagnosis of acute appendicitis unless appendectomy after successful conservative treatment or death occurred during follow-up. The median time to recurrence was 6.5 (1–17.8) months. After multivariable logistic regression analysis, external appendix diameter >10 mm [OR 2.4 (CI 1.37–4.21), p = .002] and intra-abdominal abscess [OR 2.05 (CI 1.18–3.56), p = .011] on computed tomography were significant independent risk factors for recurrent appendicitis. Appendicolith was not associated with an increased risk of recurrence. Conclusion This study suggests abscess formation and appendix distension of >10 mm to be potential risk factors for recurrent acute appendicitis after initial successful conservative treatment.

Successful conservative treatment for a non-exteriorised Vesicocutaneous fistula

Cystic cutaneous fistula refers to an abnormal passageway or tunnel that forms between a cyst and the skin surface. A cyst is a closed sac or pocket containing fluid, air, or other substances, and when a connection forms between this cyst and the outer skin, it leads to the development of a fistula. The diagnosis is mainly clinical and X ray based. Primarily affects both male and female adults. Mainly caused by infection, trauma and history of recent trans cystic or cystic surgery for bladder stones, benign prostatic hyperplasia and other causes. Although treatment usually includes antibiotics, percutaneous or open surgery procedures may be needed to treat the fistula.

Centralization as the key survival benefit in acute neonatal surgery.

Centralization of neonatal surgical care for congenital malformations is already under discussion. Acute care of neonatal emergencies in perinatal centers with affiliated hospitals is not uniformly regulated in Germany. Analyses are based on acute pediatric surgical care at four affiliated hospitals of a perinatal center. Epidemiologic data and outcome parameters "survival", "intracerebral hemorrhage", and "revision of surgical indication" are assessed. Comparison is made between patients receiving surgical treatment at affiliated hospitals (group A) and patients with transfer to the university center for therapy in case of surgical indication for gastrointestinal diseases (group B). 17 group A-patients are compared to 40 group B-patients. Comparison of epidemiological data reveals no significant differences. There is a survival advantage with transfer to the university center (mortality of 29% in group A vs. 2% in group B, p = 0.007). Intracerebral hemorrhage occurred more frequently in externally treated patients (group A 24% vs. group B 2%, p = 0.024). Surgical indication was revised in 30% of group B at the university center (p = 0.011) with consecutive successful conservative treatment. Transfer of patients at the beginning of the acute phase of gastrointestinal diseases is key to optimize the quality of neonatal surgical care. However, larger population studies should confirm the presented results, discuss restricting factors of real care structures and should rule out bias in triage of patients.

Textbook outcome in patients with biliary duct injury during cholecystectomy

BackgroundIatrogenic bile duct injury (BDI) during cholecystectomy is associated with a complex and heterogeneous management owing to the burden of morbidity until their definitive treatment. This study aimed to define the textbook outcomes (TOs) after BDI with the purpose to indicate the ideal treatment and to improve it management. MethodsWe collected data from patients with an BDI between 1990 and 2022 from 27 hospitals. TO was defined as a successful conservative treatment of the iatrogenic BDI or only minor complications after BDI or patients in whom the first repair resolves the iatrogenic BDI without complications or with minor complications. ResultsWe included 808 patients and a total of 394 patients (46.9%) achieved TO. Overall complications in TO and non-TO groups were 11.9% and 86%, respectively (P < .001). Major complications and mortality in the non-TO group were 57.4% and 9.2%, respectively. The use of end-to-end bile duct anastomosis repair was higher in the non-TO group (23.1 vs 7.8, P < .001). Factors associated with achieving a TO were injury in a specialized center (adjusted odds ratio [aOR], 4.01; 95% CI, 2.68–5.99; P < .001), transfer for a first repair (aOR, 5.72; 95% CI, 3.51–9.34; P < .001), conservative management (aOR, 5.00; 95% CI, 1.63–15.36; P = .005), or surgical management (aOR, 2.45; 95% CI, 1.50–4.00; P < .001). ConclusionTO largely depends on where the BDI is managed and the type of injury. It allows hepatobiliary centers to identify domains of improvement of perioperative management of patients with BDI.

Factors associated with false lumen changes in patients with superior mesenteric artery dissection.

False lumen changes (FLCs) are the main reference for the prognosis judgment and treatment plan selection for type IIa superior mesenteric artery dissection (SMAD). For this retrospective study, 55 patients with symptomatic type IIa SMAD were included. Computational fluid dynamics (CFD) analysis was used to explore the hemodynamic basis of FLCs. Correlation and multiple linear regression analyses were performed to identify clinical, morphological and hemodynamic factors associated with FLCs. The FLCs of patients with successful conservative treatment (n = 29) are significantly higher than those with failed conservative treatment (n = 26) (58.5 ± 21.1% vs 10.9 ± 17.4%, p < 0.0001). Positive correlations were seen between FLCs and the morphological parameters false lumen length (FLL)/dissection entrance length (DEL) and FLL. In terms of hemodynamic parameters, negative correlations were seen between FLCs and time-averaged wall shear stress (TAWSS), vorticity, and high areas of TAWSS and vorticity, whereas positive correlations were seen between FLCs and oscillatory shear index (OSI), relative residence time (RRT), and high areas of OSI and RRT. Multiple linear regression analysis identified symptom duration (odds ratio [OR], 0.93; 95% CI, 0.91-0.96; p < 0.0001), FLL/DEL (OR, 1.30; 95% CI, 1.01-1.67; p = 0.044), and high RRT area (OR, 2.03; 95% CI, 1.48-2.78; p < 0.0001) as predictors of FLCs. The clinical predictor symptom duration, morphological factor FLL/DEL, and the hemodynamic factor high RRT area can serve as predictors of FLCs in patients with symptomatic type IIa SMAD.

Successful conservative treatment of pulmonary thromboembolism in unrepaired d-transposition of the great arteries with pulmonary hypertension: a case report

Background: Unrepaired dextro-transposition of great arteries (D-TGA) is well known for long-term complications, including tricuspid valve regurgitation, arrhythmias, and coronary artery abnormalities. Pulmonary hypertension (PH) is a frequent, progressive, and fatal complication in unrepaired CHD. This chronic condition can induce pulmonary thromboembolism (PTE). Aim: To report the management of PTE in unrepaired D-TGA with PH. Case Presentation: We present a rare case of an eleven-year-old male in unrepaired D-TGA with PH. He came with hemoptysis with no sign of acute or chronic infection. This condition was not associated with endocarditis or tuberculosis. The patient underwent a CT-pulmonary angiography examination and found a filling defect in the apical and posterior branches of the right superior pulmonary artery, suggesting a PTE that caused pulmonary parenchymal infarction. He was treated with intravenous low molecular weight heparin (LMWH) for ten days (1 mg/kg) and tranexamic acid. On follow-up, he did not experience cardiovascular collapse or hypotension; by the day, the hemoptysis had decreased in frequency and volume. He received long-term warfarin (2 mg/day) for three months. After three months of follow-up, the PTE was not visualized from CT-pulmonary angiography. Summary: Hemoptysis is rare and life-threatening in unrepaired CHD. Heparin administration continued with warfarin, and tranexamic acid provides a good prognosis in patients with PTE with D-TGA and PH.

Successful conservative treatment for left ventricular free wall rupture after acute myocardial infarction

Left ventricular free wall rupture (LVFWR) is a rare but fatal complication of acute myocardial infarction (AMI). An 81-year-old female patient with several cardiovascular risk factors presented to the emergency department with symptoms of developing a chronic stomachache and cold sweat. An echocardiograph showed wall motion abnormalities from the lateral to posterior wall, as well as pericardial effusion containing clots of up to 17 mm in the posterior wall that indicated LVFWR after AMI. Although she was conscious after being brought to the initial care unit, she suddenly lost consciousness and fell into electromechanical dissociation (EMD). Endotracheal intubation was immediately initiated and her pericardial drainage and intra aortic balloon pump (IABP) placement, and hemodynamics recovered. Although she had 100% obstruction in the left circumflex artery (LCX) #12 on coronary angiography (CAG), she was discharged to the Intensive Care Unit (ICU) without percutaneous coronary intervention (PCI). Conservative treatment such as intubation, sedation, pericardiocentesis and strict blood pressure management as well as treatment by IABP long-term support led to the patient being uneventfully discharged after 60 days.

Conservative treatment of spinal tuberculosis in a retrospective cohort study over 20-year period: high eradication rate and successful health status can be expected.

Tuberculosis (TB) which mainly cause lung primarily TB, can also affect the musculoskeletal system. Spine involvement occurs in 50% of the cases and neurologic deficit and kyphotic deformity may occur. The choice of conservative or surgical management of spinal TB in the absence of neurologic deficits remains controversial. The aim of the present study was to investigate the outcome and the success rate of conservative treatment and to provide evidence for the timing of treatment for spinal TB in adult patients. Consecutive enrolled adult patients were conservatively treated from January 2000 to January 2020 for spinal TB in a tertiary care Orthopedic and Trauma Center-Spine Surgery Unit in Turin. Patients were conservatively treated with antibiotics and orthoses and followed up for at least 12 months. Clinical, radiological, laboratory and microbiological tests were performed for all the patients and demographic data, risk factors, comorbidity, clinical symptoms such as peripheral neurological deficit, and vertebral level involved were recorded. Treatment success was considered as no disease recurrence after 1 year of follow-up. Patients underwent successful conservative treatment were also evaluated with the self-perceived quality of life [36-Item Short Form (SF-36)] survey. A total of 132 patients (59 women and 73 men) suffering from spinal TB with a mean age at presentation of 49 years (range, 32-68 years) were treated. The mean follow-up was 43 months (range, 12-82 months). In 80 cases, there was a single vertebra involvement while multiple levels were involved in 52 cases. Sixty-nine (52%) patients presented spondylitis without involvement of the disk and 63 (48%) patients presented a spondylitis with disk involvement. Conservative treatment was effective in 113 patients (86%) which showed inter-somatic fusion with stability of the spine. The mean period of antibiotic therapy was 12 months (range, 8-15 months). Patients wear spinal orthosis for at least 12 weeks. The physical component summary (PCS)-36 (48.9±10.0) and mental component summary (MCS) (46.5±7.0) summary scores at follow-up were comparable to the normative values (P=0.652 and P=0.862, respectively). Painful deformity occurred in 25 patients (19%). Conservative treatment is effective treatment for spinal TB and may avoid surgical intervention in the absence of neurologic deficits.

Multidisciplinary management of acute cholecystitis during the COVID-19 pandemic

The coronavirus disease 2019 pandemic had a major impact on most medical services. Our aim was to assess the outcome of acute cholecystitis during the nationwide lockdown period. All patients admitted to our emergency department for AC were analysed. Patient characteristics, performance status, AC severity, treatment modality and outcome of AC were assessed during the lockdown period (Period II: 1 April 2020–30 November 2021) and compared to a historical control period (Period I: 1 May 2017–31 December 2018). AC admissions increased by 72.8% in Period II. Patients were younger (70 vs. 74 years, p = 0.017) and greater in number in the CCI 1 group (20.4% vs. 11.2%, p = 0.043) in Period II. The unplanned readmission rate (6.3 vs. 0%, p = 0.004) and the gallbladder perforation (GP) rate was higher (18.0 vs. 7.3%, p = 0.006) in Period II. Percutaneous transhepatic gallbladder drainage (PTGBD) was more frequent (24.1 vs. 12.8%, p = 0.012) in Period II. In addition to a drop in patient age and CCI, a significant rise in the prevalence of acute cholecystitis, GP and unplanned readmissions was observed during the nationwide lockdown due to the COVID-19 pandemic. PTGBD was more frequent during this period, whereas successful conservative treatment was less frequent.

Successful conservative treatment for massive tracheal necrosis after lung segmentectomy

BackgroundTracheal necrosis, which is rare because the trachea has rich in blood supply, can be a serious condition. Herein, we report the case of extensive tracheal necrosis that developed after right apical segmentectomy for a metastatic lung tumor of esophageal cancer.Case presentationA 74-year-old man who had undergone thoracoscopic subtotal esophagectomy and gastric tube reconstruction via the posterior sternal route for esophageal adenocarcinoma 2 years previously was referred to our department with an enlarging nodal lesion in the right upper lung lobe. Computed tomography revealed a 30-mm tumor in the right apical segment with no lymph node enhancement, suggesting primary lung cancer or a metastatic lung tumor. The patient underwent right apical segmentectomy. The upper lobe was adherent to the chest wall and mediastinal fat from the apex of the lung to the dorsal side, with particularly strong adhesion at the esophagectomy site. After dissecting the adhesions, right apical segmentectomy was performed via complete video-assisted thoracic surgery. The patient was discharged on the 9th day after surgery without any complications. Pathologic findings revealed a metastatic lung tumor originating from the patient’s esophageal cancer. On the 26th day after surgery, the patient returned with dyspnea and increased sputum. Computed tomography images revealed that the posterior wall of the trachea was missing an area of 16 × 42 mm and was connected to the dead space after the right apical segmentectomy, with no effusion. We diagnosed extensive tracheal necrosis. Considering that the patient’s status was very well despite the extensive tracheal necrosis, we chose conservative treatment. After receiving 12 days of intravenous antibiotic treatment, his symptoms improved, and he was discharged on day 26 after admission.ConclusionsRight upper lung lobe resection after esophagectomy has a risk of tracheal necrosis. Conservative treatment is one approach to manage massive tracheal necrosis in patients with stable respiratory conditions.

Conservative management of multi-trauma induced peritonitis: Experience, outcomes, and indications.

The concept of mandatory laparotomy in treating traumatic peritonitis has been increasingly questioned recently. To summarize and share the experience of conservative treatment of patients with multi-trauma induced peritonitis. A retrospective review was performed on patients with multiple injury induced traumatic peritonitis. A total of 184 patients with multiple injury induced traumatic peritonitis were reviewed. 46 of them underwent conservative treatment. None of the 46 patients with conservative treatment switched to surgical treatment, and all of them were cured and discharged after successful conservative treatment. No significant abnormal findings were observed at regular follow-up after discharge. Conservative management is safe, effective, feasible, and beneficial in hemodynamically stable patients with traumatic peritonitis if there is no definite evidence of severe abdominal visceral organ injury.

Development of internal carotid artery aneurysm after successful conservative treatment of prolactinoma

Background. The problem of concomitant pituitary adenomas and intracranial aneurysms is extensively covered in literature. According to various authors, the prevalence of such a combination of lesions is as high as 9 %, most commonly involving hormone‑producing pituitary adenomas and aneurysms of the anterior circulation, up to 69 % of which originate from the carotid artery.Aim. To analyze and demonstrate the treatment of patients with developed internal carotid artery aneurysm (ICA) against the background of successful conservative therapy of prolactinoma. Materials and methods. In this article we review the literature and present two clinical cases of patients with development of internal carotid artery (ICA) aneurysms after successful conservative treatment of prolactinomas.Results. In both of the described cases, ICA aneurysms with intrasellar extension developed after successful conservative treatment of large invasive prolactinomas. In both cases ICA occlusion were performed and in one of them extra‑intracranial bypass surgery was performed as well.Conclusion. The presented clinical cases suggest potential direct destructive effect of tumor tissue on vessel walls. Currently, it seems reasonable to carry out computed tomography angiography in all patients with adenomas invading the cavernous sinus.

Detection of Elbow OCD in the Ultrasound Image by Artificial Intelligence Using YOLOv8

Background: Screening for elbow osteochondritis dissecans (OCD) using ultrasound (US) is essential for early detection and successful conservative treatment. The aim of the study is to determine the diagnostic accuracy of YOLOv8, a deep-learning-based artificial intelligence model, for US images of OCD or normal elbow-joint images. Methods: A total of 2430 images were used. Using the YOLOv8 model, image classification and object detection were performed to recognize OCD lesions or standard views of normal elbow joints. Results: In the binary classification of normal and OCD lesions, the values from the confusion matrix were the following: Accuracy = 0.998, Recall = 0.9975, Precision = 1.000, and F-measure = 0.9987. The mean average precision (mAP) comparing the bounding box detected by the trained model with the true-label bounding box was 0.994 in the YOLOv8n model and 0.995 in the YOLOv8m model. Conclusions: The YOLOv8 model was trained for image classification and object detection of standard views of elbow joints and OCD lesions. Both tasks were able to be achieved with high accuracy and may be useful for mass screening at medical check-ups for baseball elbow.

Unenhanced CT-based predictive model to identify small bowel necrosis in patients with mechanical small bowel obstruction

ObjectivesTo investigate the diagnostic value of unenhanced CT in mechanical small bowel obstruction (SBO) with small bowel necrosis, and to establish a predictive model.MethodsFrom May 2017 to December 2021, the patients with mechanical SBO admitted to our hospital were retrospectively collected. Taking pathology-confirmed small bowel necrosis as the gold standard, the experimental group was composed of patients with small bowel necrosis confirmed by pathology, and the control group was composed of patients with no intestinal necrosis confirmed by surgery or successful conservative treatment with no recurrence of intestinal obstruction during 1-month followed-up.ResultsA total of 182 patients were enrolled in this study, 157 patients underwent surgery, of which 35 patients were accompanied with small bowel necrosis and 122 patients were not (33 patients with ischemic findings at surgery without necrosis). Finally, there were 35 patients in the experimental group and 147 patients in the control group. Multivariable logistic regression showed that increased attenuation of small bowel wall (P = 0.002), diffuse mesenteric haziness (P = 0.010), difference of CT value between mesenteric vessel and aorta (P = 0.025) and U-/C-shaped small bowel loop (P = 0.010) were independent risk factors for the diagnosis of mechanical SBO with small bowel necrosis. Through internal verification, the area under curve (AUC) of the predictive model reached 0.886 (95%CI: 0.824–0.947), and the calibration result was moderate.ConclusionMultiple features (increased attenuation of small bowel wall; difference of CT values between mesenteric vessel and aorta; diffuse mesenteric haziness; and U-/C-shaped small bowel loop) of unenhanced CT have clinical value in the diagnosis of mechanical SBO with small bowel necrosis. The predictive model based on these four features could achieve satisfactory efficiency.

Needle Arthroscopic Inspection and Treatment of (Osteo)chondral Lesions of the Ankle in Unstable Syndesmotic Injuries Treated With Suture Button Fixation: A Standardized Approach

Both acute and chronic syndesmotic injuries are associated with (osteo)chondral lesions of the ankle in at least 1 out of 5 patients. Having a common denominator of an acute traumatic injury being external rotation and forced dorsiflexion, the injury of a combined unstable syndesmotic injury and a potentially present concomitant (osteo)chondral lesion to the ankle warrants a thorough diagnostic and interventional approach. Furthermore, early diagnosis may prevent further damage to the joint through lifestyle changes and increase the chances of successful conservative or surgical treatment, potentially reducing the progression toward end-stage osteoarthritis. Consequently, technological advances and financial considerations have led to the development of a minimally invasive needle arthroscopic inspection and treatment of concomitant (osteo)chondral injuries of the ankle in the combined treatment of unstable syndesmotic injuries with suture button fixation. The present Technical Note describes this innovative minimally invasive assessment and concomitant treatment technique.

Successful conservative treatment of cutaneous larva migrans syndrome in a child

Introduction. The cutaneous larva migrans syndrome is a common disease in the tropical zone. But in the countries with a different climate , like in Russia, this pathology is rarely met; thus, practicing physicians have not enough experience and knowledge about this disease .Clinical observation. The authors describe their experience in treating cutaneous larva migrans syndrome in a one-year old child. After studying literature sources, the authors understood that they were facing a typical clinical picture of this pathology. It was an interesting fact that neither patient, nor her parents travelled outside Russia. The authors also demonstrate the effectiveness of the prescribed treatment.Conclusion. The above observation underlines that sporadic cases of larva migrans syndrome are quite possible at the territory of Russia. The effectiveness of Albendazole for managing this pathology in young children was also confirmed.

Perigastric abscess caused by delayed perforation after gastric endoscopic submucosal dissection: successful conservative treatment without perforation closure: a case report

BackgroundPerigastric abscess caused by delayed perforation after endoscopic submucosal dissection is a very rare complication. In principle, delayed perforation after endoscopic submucosal dissection is treated surgically. Herein, we report a case of perigastric abscess caused by delayed perforation after gastric endoscopic submucosal dissection that was treated conservatively, without perforation closure, and in which the patient was discharged from hospital in a short period.Case presentationA-74-year-old Asian man was diagnosed with having early gastric cancer on follow-up endoscopy and was admitted to our hospital for endoscopic resection. Endoscopic submucosal dissection was performed without intraoperative complications. On postoperative day 2, the patient complained of a slight abdominal pain localized to the epigastric region and a small amount of melena. A computed tomography scan revealed the presence of free air in the peritoneal cavity, and a little fluid collection abutting the dorsal area of the stomach. An endoscopy examination showed a deep ulcer with the accumulation of pus, suggesting a perforation in the post-endoscopic submucosal dissection ulcer. We diagnosed a perigastric abscess, caused by delayed perforation after endoscopic submucosal dissection, and opted for conservative treatment, leaving the perforation site open to allow spontaneous drainage from the abscess into the stomach. A follow-up computed tomography scan revealed an encapsuled and localized perigastric abscess on postoperative day 5, and the disappearance of the free air and the regression of the perigastric abscess on postoperative day 7. A follow-up endoscopy examination on postoperative day 7 showed the closure of the perforation. Finally, surgery was avoided, and the patient was discharged on postoperative day 14, after a relatively short hospital stay.ConclusionRegarding the treatment of perigastric abscess, caused by delayed perforation after endoscopic submucosal dissection, leaving the perforation site open to allow spontaneous drainage may shorten the conservative treatment period.

The Volume of Intestinal Decompression can Predict the Necessity of Surgical Intervention for Adhesive Small Bowel Obstruction

BackgroundThere is no standard timing for switching to surgical management for children with adhesive small bowel obstruction (ASBO) who initially receive conservative treatment. We hypothesized that an increased gastrointestinal drainage volume may indicate the need for surgical intervention. MethodsThe study population included 150 episodes in the patients less than 20 years of age who received treatment for ASBO in our department from January 2008 to August 2019. Patients were divided into two groups: the successful conservative treatment group (CT) and the eventual surgical treatment group (ST). Following the analysis of all episodes (Study 1), we limited our analysis to only first ASBO episodes (Study 2). We retrospectively reviewed their medical records. ResultsThere were statistically significant differences in the volume on the 2nd day in both Study 1 (9.1 ml/kg vs. 18.7 ml/kg; p < 0.01) and study 2 (8.1 ml/kg vs. 19.7 ml/kg; p < 0.01). The cut-off value was the same for both Study 1 and Study 2 (11.7 ml/kg). ConclusionsThe gastrointestinal drainage volume on the 2nd day in ST was significantly larger than that in CT. Accordingly, we considered that the drainage volume may predict eventual surgical intervention for children with ASBO who initially receive conservative treatment. Level of evidenceLevel IV.

Management of proximal rectus femoris injuries - do we know what we're doing?: A systematic review.

Rectus femoris (RF) injury is a concern in sports. The management RF strains/tears and avulsion injuries need to be clearly outlined. A systematic review of literature on current management strategies for RF injuries, and to ascertain the efficacy thereof by the return to sport (RTS) time and re-injury rates. Literature search using Medline via PubMed, WorldCat, EMBASE, SPORTDiscus. Eligible studies were reviewed. Thirty-eight studies involving hundred and fifty-two participants were included. Majority (n = 138; 91%) were males, 80% (n = 121) sustained RF injury from kicking and 20% (n = 31) during sprinting. The myotendinous (MT), (n = 27); free tendon (FT), (n = 34), and anterior-inferior iliac spine (AIIS), (n = 91) were involved. Treatment was conservative (n = 115) or surgical (n = 37) across the subgroups. 73% (n = 27) of surgical treatments followed failed conservative treatment. The mean RTS was shorter with successful conservative treatment (MT: 1, FT: 4, AIIS avulsion: 2.9 months). Surgical RTS ranged from 2-9 months and 18 months with labral involvement. With either group, there was no re-injury within 24 months follow-up. With low certainty of evidence RF injury occurs mostly from kicking, resulting in a tear or avulsion at the FT and AIIS regions with or without a labral tear. With low certainty, findings suggest that successful conservative treatment provides a shortened RTS. Surgical treatment remains an option for failed conservative treatment of RF injuries across all subgroups. High-level studies are recommended to improve the evidence base for the treatment of this significant injury.

Successful conservative treatment for Ogden type-IV tibial tubercle avulsion fracture with transverse fibular fracture in 15 years old boy in remote area: a case report

Background: Tibial tubercle avulsion fracture is very rare. Its incidence has been reported to account for only 3% of all proximal tibia fractures and less than 1% of all growth plate injuries. This fracture occurs when the quadriceps are forcefully contracted against resistance, such as during jumping, or when rapid knee flexion occurs with contracted quadriceps, such as during landing. Most authors recommended surgical options in type IV tibial tubercle avulsion; however, we reported successful conservative treatment in this case report. Case report: A 15-year-old male athlete with no significant past medical history presented via emergency medical services after a ground-level fall while playing basketball which landed with his left foot in a pivot position. He felt immediate pain and swelling about the left knee, all sensation was intact, as were pedal pulses, and neurovascularly remained intact. The patient did not want to go for medical evacuation to do surgery and consent to be managed with conservative treatment with close follow-up. Conclusion: The results and prognosis of these fractures are excellent, despite the fracture pattern or treatment used, as long as an anatomical reduction is obtained