Treatment of osteochondral defects of the talus in children.

PURPOSE: Osteochondral talar defects are infrequent in children, and little is known about the treatment and clinical outcome of these defects. The purpose of this study was to evaluate the clinical and radiographic outcomes of conservative and primary surgically treated osteochondral talar defects in skeletally immature children. METHODS: Thirty-six (97%) of 37 eligible patients with a symptomatic primary osteochondral talar defect were evaluated after a median follow-up of 4 years (range 1-12 years). Clinical assessment included the Berndt and Harty outcome question, Ogilvie-Harris score, Visual Analog Scale pain score (at rest, during walking and during running), the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the SF-36. Weight-bearing radiographs were compared with preoperative radiographs with the use of an ankle osteoarthritis classification system. RESULTS: Ninety-two per cent of the initially conservatively treated children [mean age 13 years (SD 2)] were eventually scheduled to undergo surgery. After fixation of the fragment, seven cases (78%) reported a good Berndt and Harty outcome, and two cases (22%) a fair outcome; the median AOFAS score was 95.0 (range 77-100). After debridement and bone marrow stimulation, 13 cases (62%) reported a good Berndt and Harty outcome, three cases (14%) a fair outcome, and five cases (24%) a poor outcome; the median AOFAS score was 95.0 (range 45-100). No signs of degenerative changes were seen in both groups at follow-up. CONCLUSIONS: Fixation and debridement and bone marrow stimulation of an osteochondral talar defect are both good surgical options after failed conservative treatment. LEVEL OF EVIDENCE: Retrospective case series, Therapeutic, Level IV.

Treatment of dysplasia epiphysealis hemimelica: a systematic review of published reports and a report of seven patients.

Dysplasia epiphysealis hemimelica is a rare entity. It is characterized by cartilage overgrowth in the epiphyses and is considered to be an epiphyseal osteochondroma. It usually presents during childhood and can cause pain and functional limitations. The aim of the present study was to describe the entity through our cases and published data and to present the results of our suggested treatment. A systematic search was performed to retrieve and describe all studies on dysplasia epiphysealis hemimelica. Studies were included if sufficient information on the patient characteristics, lesion location, treatment, and outcomes were described. In addition, we report on 7 of our patients. In our review, 48 studies were found, of which 42 could be included. Owing to the large heterogeneity in the studies, no pooling of data was performed. The studies included 138 patients with 255 lesions. Approximately 27% were female patients. The age at presentation ranged from 3 months to 66 years; however, in most, the entity was discovered before 8 years of age. No apparent guidelines were presented concerning the treatment strategy; however, most investigators performed resection because of pain or limitations in the range of motion. Most lesions were located in the ankle or foot (139 of 255). In our own cases, 5 of 7 patients experienced pain, limited range of motion, or activity restriction. The mean follow-up period was 4 years. Dysplasia epiphysealis hemimelica is a rare entity, occurring predominantly in the lower extremity of in young male patients. Its aggressive growth warrants aggressive treatment in the case of pain or functional or range of motion limitations.

Inflammatory arthritis complicating galactosialidosis: a case report.

BACKGROUND: Galactosialidosis (GS) is a rare inherited lysosomal storage disorder (LSD) which is characterized by a defect in the lysosomal glycoprotein catabolism. We report, for the first time, the case of a child affected by GS presenting with recurrent episodes of extensive joint inflammation in both knee joints. The aim of this case-report is to describe the clinical presentation as well as the laboratory, radiologic and microscopic features of this unique presentation of GS. Furthermore, we explore inflammatory mechanisms potentially responsible for the origination of the arthritic joint pathology observed in our patient. CASE PRESENTATION: We describe the rare case of a 12-year-old boy diagnosed with GS (late infantile form) who presented with multiple episodes of inflammatory arthritis involving both knees; no other joints were suspected for joint inflammation. Laboratory results did not indicate an autoimmune disorder. Synovial fluid tested negative for any bacterial infection and ruled out a malignancy and crystal-induced arthritis. Microscopic examination of the synovial tissue revealed numerous foamy macrophages with extensive vacuolization, consistent with the previous diagnosis of GS. Treatment consisted of aspiration of excessive joint fluid and subsequent intra-articular injection of triamcinolonhexacetonide with excellent but transient result. Given the evidence of storage products within macrophages of the inflamed synovial tissue and the absence of other etiological clues, GS itself was considered as the primary cause for the relapsing inflammatory joint pathology. According to the restricted data on articular manifestations in GS, to date, GS cannot be linked directly to joint inflammation. Nevertheless, in several other LSDs, the accumulation of storage material has been associated with numerous osteoimmunological changes that might play a role in the pathophysiology of arthritic processes. CONCLUSIONS: We hypothesize that the articular build-up of GS storage products triggered systemic as well as local inflammatory processes, resulting in the extensive inflammatory joint pathology as observed in our patient. Future identification of other patients with GS is required to corroborate the existence of an arthritic clinical phenotype of GS and to assess the underlying pathophysiology.

Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults.

BACKGROUND: Ankle sprains are one of the most commonly treated musculoskeletal injuries. The three main treatment modalities for acute lateral ankle ligament injuries are immobilisation with plaster cast or splint, 'functional treatment' comprising early mobilisation and use of an external support (e.g. ankle brace), and surgical repair or reconstruction. OBJECTIVES: We aimed to compare surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2006), the Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to December 2005), EMBASE, CINAHL and reference lists of articles, and contacted researchers in the field. This review is considered updated to January 2006. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing surgical with conservative interventions for treating ankle sprains in adults. DATA COLLECTION AND ANALYSIS: At least two authors independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled. We performed sensitivity analyses to explore the robustness of the findings. MAIN RESULTS: Twenty trials were included. These involved a total of 2562 mostly young active adult males. All trials had methodological weaknesses. Specifically, concealment of allocation was confirmed in only one trial. Data for pooling individual outcomes were only available for a maximum of 12 trials and under 60% of participants. The findings of statistically significant differences in favour of the surgical treatment group for the four primary outcomes (non-return to pre-injury level of sports; ankle sprain recurrence; long-term pain; subjective or functional instability) when using the fixed-effect model were not robust when using the random-effects model, nor on the removal of one low quality (quasi-randomised) trial that had more extreme results. A corresponding drop in the I(2) statistics showed the remaining trials to be more homogeneous. The functional implications of the statistically significantly higher incidence of objective instability in conservatively treated trial participants are uncertain. There was some limited evidence for longer recovery times, and higher incidences of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group. AUTHORS' CONCLUSIONS: There is insufficient evidence available from randomised controlled trials to determine the relative effectiveness of surgical and conservative treatment for acute injuries of the lateral ligament complex of the ankle. High quality randomised controlled trials of primary surgical repair versus the best available conservative treatment for well-defined injuries are required.

Cost effectiveness of brace, physiotherapy, or both for treatment of tennis elbow.

BACKGROUND: The annual incidence of tennis elbow in the general population is high (1-3%). Tennis elbow often leads to limitation of activities of daily living and work absenteeism. Physiotherapy and braces are the most common treatments. OBJECTIVES: The hypothesis of the trial was that no difference exists in the cost effectiveness of physiotherapy, braces, and a combination of the two for treatment of tennis elbow. METHODS: The trial was designed as a randomised controlled trial with intention to treat analysis. A total of 180 patients with tennis elbow were randomised to brace only (n = 68), physiotherapy (n = 56), or a combination of the two (n = 56). Outcome measures were success rate, severity of complaints, pain, functional disability, and quality of life. Follow up was at six, 26, and 52 weeks. Direct healthcare and non-healthcare costs and indirect costs were measured. Mean cost differences over 12 months were evaluated by applying non-parametric bootstrap techniques. RESULTS: No clinically relevant or statistically significant differences were found between the groups. Success rate at 12 months was 89% in the physiotherapy group, 86% in the brace group, and 87% in the combination group. Mean total costs per patient were 2069 euros in the brace only group, 978 euros in the physiotherapy group, and 1256 euros in the combination group. The mean difference in total costs between the physiotherapy and brace group was substantial (1005 euros), although not significant. Cost effectiveness ratios and cost utility ratios showed physiotherapy to be the most cost effective, although this also was not statistically significant. CONCLUSION: No clinically relevant or statistically significant differences in costs were identified between the three strategies.

Conservative treatment for closed fifth (small finger) metacarpal neck fractures.

BACKGROUND: Subcapital fractures of the fifth metacarpal bone, meaning fractures just below the knuckle of the little finger, account for approximately 20% of all hand fractures. Currently, there is no consensus concerning the optimal management of these fractures. Traditionally, treatment consists of closed reduction and external splinting in a neutral position using plaster of Paris (POP), involving the metacarpal joint, the proximal interphalangeal joint and the carpo-metacarpal joint. An alternative treatment strategy is functional treatment using taping or bracing that does not restrict movement. OBJECTIVES: To compare functional treatment with immobilization, and to compare different periods and types of immobilization, for the treatment of closed fifth metacarpal neck fractures in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (July 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2004), OVID OldMEDLINE (1951 to 1965), OVID MEDLINE (1966 to July 2004), OVID MEDLINE In-Process (July 2004), EMBASE (1988 to 2004, week 29), the Internet, and reference lists of articles. No language restrictions were applied. SELECTION CRITERIA: All randomized and quasi-randomized controlled trials which compare functional treatment with immobilization or different types of immobilization for closed fifth metacarpal neck fractures. DATA COLLECTION AND ANALYSIS: Two review authors assessed abstracts of all studies identified by the initial search, identified studies meeting the selection criteria, independently assessed the quality of the trial reports, and extracted and analysed the data. MAIN RESULTS: Five studies met the inclusion criteria including a total of 252 participants. Most studies were of poor quality. The primary outcome measure, function of the hand, was not used in any studies. There was no evidence that any of the treatment modalities was statistically significantly superior. AUTHORS' CONCLUSIONS: No included studies reported our primary outcome measure of interest, validated hand function. There was heterogeneity between the studies, which were of limited quality and size. No single non-operative treatment regimen for fracture of the neck of the fifth metacarpal can be recommended as superior to another in result. Further research is definitely warranted.

Orthotic devices for tennis elbow: a systematic review.

Lateral epicondylitis (tennis elbow) is af requently reported condition. A wide variety of treatment strategies has been described. Asy et, no optimal strategy has been identified. The aim of this review was to assess the effectiveness of orthotic devices for treatment of tennis elbow. An electronic database search was conducted using MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trial Register Current Contents, and reference listsf rom all retrieved articles. Experts on the subjects were approachedfor additional trials. All randomised controlled trials (RCTs) descrbiing individuals with diagnosed lateral epicondylitis and assessing the use of an orthotic device as a treatment strategy were evaluatedfor inclusion. Two reviewers independently assessed the validity of the included trials and extracted data on relevant outcome measures. Dichotomous outcomes were expressed as relative risks and continuous outcomes as standardised mean differences, both with corresponding 95% confidence intervals. Statistical pooling and subgroup analyses were intended. Five small-size RCTs (n = 7-49 per group) were included the validity score ranged from three to nine positive items out of 11. Subgroup analyses were not performed owing to the small number of trials. The limited number of included trials present few outcome measures and limited long-term results. Pooling was not possible owing to the high level of heterogeneity of the trials. No definitive conclusions can be drawn concerning effectiveness of orthotic devices for lateral epicondylitis. More well-designed and well-conducted RCTs of sufficient power are warranted.

Orthotic devices for tennis elbow.

BACKGROUND: Lateral epicondylitis (tennis elbow) is a frequently reported condition. A wide variety of treatment strategies has been described. As of yet, no optimal strategy has been identified. OBJECTIVES: The objective of this review was to assess the effectiveness of orthotic devices for treatment of tennis elbow. SEARCH STRATEGY: An electronic database search was conducted using Medline, Embase, Cinahl, the Cochrane Controlled Trial Register, Current Contents and reference lists from all retrieved articles. Experts on the subjects were approached for additional trials. SELECTION CRITERIA: All randomised clinical trials (RCT) describing individuals with diagnosed lateral epicondylitis and comparing the use of an orthotic device as a treatment strategy were evaluated for inclusion. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the validity of the included trials and extracted data on relevant outcome measures. Dichotomous outcomes were expressed as Relative Risks (RRs) and continuous outcomes as Standardised Mean Differences (SMD), both with corresponding 95% confidence intervals (95% CI). Statistical pooling and subgroup analyses were intended MAIN RESULTS: Five small-size RCTs (N per group 7-49) were included. Validity score ranged from 3-9 positive items out of 11. Subgroup analyses were not performed due to the small number of trials. The limited number of included trials present few outcome measures and limited long-term results. Pooling was not possible due to large heterogeneity amongst trials. REVIEWER'S CONCLUSIONS: No definitive conclusions can be drawn concerning effectiveness of orthotic devices for lateral epicondylitis. More well-designed and well-conducted RCTs of sufficient power are warranted.

Orthotic devices for treating patellofemoral pain syndrome.

BACKGROUND: Patellofemoral pain syndrome is a frequently reported condition in active adults. A wide variety of conservative treatment strategies have been described. As yet, no optimal strategy has been identified. Application of orthotic devices e.g. knee braces, knee straps, forms of taping of the knee, active training devices, knee sleeves and in-shoe orthotics to support the foot have been advocated to treat this condition. OBJECTIVES: To assess the effectiveness of foot and knee orthotics for treatment of patellofemoral pain syndrome. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2001), the Cochrane Controlled Trials register (Issue 2, 2000), MEDLINE (January 1966 to March 2000; EMBASE (January 1988 to March 2000); CINAHL (January 1982 to March 2000) and PEDro (up to March 2000). Relevant orthotic companies were contacted. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing the effectiveness of knee or foot orthotics for treatment of patellofemoral pain syndrome were selected. Trials describing the use of orthotic devices in conjunction with operative treatment were excluded. DATA COLLECTION AND ANALYSIS: Three reviewers independently assessed methodological quality of the identified trials by use of a modified version of the Cochrane Musculoskeletal Injuries Group assessment tool, consisting 11 items. Two reviewers extracted data without blinding. Trialists were contacted to obtain missing data. MAIN RESULTS: Five trials involving 362 participants were included in this review. Five other trials await possible inclusion if further information can be obtained and one awaits further assessment. Due to clinical heterogeneity, we refrained from statistical pooling and conducted analysis by grading the strength of scientific evidence. The level of obtained research-based evidence was graded as limited as all trials were of low methodological quality. This limited research-based evidence showed the Protonics orthosis at six week follow-up was significantly more effective for decrease in pain (weighted mean difference (WMD) between groups 3.2; 95% confidence interval (CI) 2.8 to 3.6), functional improvement on the Kujala score (WMD 45.6; 95% CI 43.4 to 47.7) and change in patellofemoral congruence angle (WMD 17.2; 95% CI 14.1 to 20.3) when compared to no treatment. A comprehensive programme including tape application was significantly superior to a monitored exercise programme without tape application for decrease in worst pain (WMD 1.6; 95% CI 0.4 to 2.8) and usual pain (WMD 1.2; 95% CI 0.2 to 2.1), and clinical change and functional improvement questionnaire scores (WMD 10, 95% CI 2.07 to 17.93) at four weeks follow-up. The trials reported statistically significant differences in patient satisfaction after applied therapy (WMD 3.3; 95% CI 0.5 to 6.1) in favour of the McConnell regimen compared with the Coumans bandage at six weeks follow-up. REVIEWER'S CONCLUSIONS: The evidence from randomised controlled trials is currently too limited to draw definitive conclusions about the use of knee and foot orthotics for the treatment of patellofemoral pain. Future high quality trials in this field are warranted.

Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults.

BACKGROUND: Inversion injuries, primarily sprains, of the ankle are one of the most commonly treated injuries. The three main treatment modalities for acute lateral ankle ligament injuries are immobilisation with plaster cast or splint, 'functional treatment' comprising early mobilisation and the use of an external support (e.g. ankle brace or taping), and surgical repair or reconstruction. OBJECTIVES: We aimed to compare surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2001), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to May 2000), EMBASE (1980 to May 2000), CURRENT CONTENTS (1993 to 1999), BIOSIS (to 1999), reference lists of articles, and contacted organisations and researchers in the field. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing surgical with conservative interventions for treating acute injuries to the lateral ligament complex of the ankle in adults. DATA COLLECTION AND ANALYSIS: At least two, usually three, reviewers independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled using fixed and random effects models and relative risks with 95% confidence intervals for dichotomous outcomes calculated. Heterogeneity between trials was tested using a standard chi-squared test. We undertook sensitivity analyses to explore the effects of inclusion of quasi-randomised trials and subgroup analyses by the two main methods of conservative treatment. MAIN RESULTS: Seventeen studies, involving a total of 1950 mostly young active adult males, were included. All trials had methodological flaws. In particular, allocation was rated as effectively concealed in only one trial and there was no report of masking outcome assessors to the interventions in any trial. Outcome measures were variously defined and data for pooling for individual outcomes were only available for a maximum of 11 studies. While there were statistically significant differences for three primary outcomes (non-return to pre-injury level of sports; undefined pain or pain on activity; and subjective or functional instability) in favour of the surgical treatment group using the fixed effects model, these findings failed to demonstrate robustness in sensitivity analyses. Exclusion of the data from explicitly quasi-randomised trials or, given the highly statistically significant heterogeneity, analyses using the random effects model modified these findings to non-statistically significant differences. There was no statistically significant difference in ankle sprain recurrence, the other primary outcome measure. Though there was a statistically significantly higher incidence of objective instability in conservatively treated patients, the functional implications of this are uncertain. There was some evidence for a lower incidence of long-term ankle swelling in surgically treated patients. However, as well as tending to take longer to resume normal activities, including work, there was some limited evidence from a few trials for a higher incidence of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group. Subgroup analyses by type of conservative treatment (plaster cast or functional treatment) revealed no statistically significant differences in effect for any of the six outcomes examined. REVIEWER'S CONCLUSIONS: There is insufficient evidence available from randomised controlled trials to determine the relative effectiveness of surgical and conservative treatment for acute injuries of the lateral ligament complex of the ankle. Sufficiently powered, good quality and adequately reported randomised trials of primary surgical repair versus the best available conservative treatment for well-defined injuries are required.

Different functional treatment strategies for acute lateral ankle ligament injuries in adults.

BACKGROUND: Acute lateral ankle ligament ruptures are common problems in present health care. Early mobilisation and functional treatment are advocated as a preferable treatment strategy. However, functional treatment comprises a broad spectrum of treatment strategies and as of yet no optimal strategy has been identified. OBJECTIVES: The objective of this review is to assess different functional treatment strategies for acute lateral ankle ligament ruptures in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2001), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to May 2000), EMBASE (1980 to May 2000), CURRENT CONTENTS (1993 to 1999), BIOSIS (to 1999), reference lists of articles, and contacted organisations and researchers in the field. SELECTION CRITERIA: Randomised clinical trials describing skeletally mature individuals with an acute lateral ankle ligament rupture and comparing different functional treatment strategies were evaluated for inclusion. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the quality of included trials and extracted relevant data on treatment outcome. Where appropriate, results of comparable studies were pooled. Individual and pooled statistics are reported as relative risks (RR) for dichotomous outcome and (weighted) mean differences (WMD) for continuous outcome measures with 95 per cent confidence intervals (95%CI). Heterogeneity between trials was tested using a standard chi-squared test. MAIN RESULTS: Nine trials involving 892 participants were included. Lace-up ankle support had significantly better results for persistent swelling at short-term follow up when compared with semi-rigid ankle support (RR 4.19, 95% CI 1.26 to 13.98); elastic bandage (RR 5.48; 95% CI 1.69 to 17.76); and to tape (RR 4.07, 95% CI 1.21 to 13.68). Use of a semi-rigid ankle support resulted in a significantly shorter time to return to work when compared with an elastic bandage (WMD (days) 4.24; 95% CI 2.42 to 6.06); one trial found the use of a semi-rigid ankle support saw a significantly quicker return to sport compared with elastic bandage (RR 9.60; 95% CI 6.34 to 12.86) and another trial found fewer patients reported instability at short-term follow-up when treated with a semi-rigid support than with an elastic bandage (RR 8.00; 95% CI 1.03 to 62.07). Tape treatment resulted in significantly more complications, the majority being skin irritations, when compared with treatment with an elastic bandage (RR 0.11; 95% CI 0.01 to 0.86). No other results showed statistically significant differences. REVIEWER'S CONCLUSIONS: The use of an elastic bandage has fewer complications than taping but appears to be associated with a slower return to work and sport, and more reported instability than a semi-rigid ankle support. Lace-up ankle support appears to be effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape. However, definitive conclusions are hampered by the variety of treatments used, and the inconsistency of reported follow-up times. The most effective treatment, both clinically and in costs, is unclear from currently available randomised trials.

Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults.

BACKGROUND: Acute lateral ankle ligament injuries (ankle sprains) are common problems in acute medical care. The treatment variation observed for the acutely injured lateral ankle ligament complex suggests a lack of evidence-based management strategies for this problem. OBJECTIVES: The objective of this review was to assess the effectiveness of methods of immobilisation for acute lateral ankle ligament injuries and to compare immobilisation with functional treatment methods. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2001); the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966-May 2000), EMBASE (1988-May 2000), reference lists of articles, and contacted organisations and researchers in the field. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing either different types of immobilisation or immobilisation versus functional treatments for injuries to the lateral ligament complex of the ankle in adults were included. Trials which investigated the treatment of chronic instability or post-surgical treatment were excluded. DATA COLLECTION AND ANALYSIS: Data were independently extracted by two authors. Where appropriate, results of comparable studies were pooled using fixed effects models. Individual and pooled statistics were reported as relative risks with 95% confidence intervals for dichotomous outcomes and weighted (WMD) or standardised (SMD) mean differences and 95% confidence intervals for continuous outcome measures. Heterogeneity between trials was tested using a standard chi-squared test. MAIN RESULTS: Twenty-one trials involving 2184 participants were included. The mean validity score of the included trials increased from 9.1 (SD 3.0) to 10 (SD 2.9) after retrieving further information (maximum 18 points). Statistically significant differences in favour of functional treatment when compared with immobilisation were found for seven outcome measures: more patients returned to sport in the long term (relative risk (RR) 1.86, 95% confidence interval (CI) 1.22 to 2.86); the time taken to return to sport was shorter (WMD 4.88 (days), 95% CI 1.50 to 8.25); more patients had returned to work at short term follow-up (RR 5.75, 95% CI 1.01 to 32.71); the time taken to return to work was shorter (WMD 8.23 days, 95% CI 6.31 to 10.16); fewer patients suffered from persistent swelling at short term follow-up (RR 1.74, 95% CI 1.17 to 2.59); fewer patients suffered from objective instability as tested by stress X-ray (WMD 2.60, 95% CI 1.24 to 3.96); and patients treated functionally were more satisfied with their treatment (RR 1.83, 95% CI 1.09 to 3.07). A separate analysis of trials that scored 50 per cent or more in quality assessment found a similar result for time to return to work only (WMD (days) 12.89, 95% CI 7.10 to 18.67). No significant differences between varying types of immobilisation, immobilisation and physiotherapy or no treatment were found, apart from one trial where patients returned to work sooner after treatment with a soft cast. In all analyses performed, no results were significantly in favour of immobilisation. REVIEWER'S CONCLUSIONS: Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated.

Orthotic devices for the treatment of tennis elbow.

BACKGROUND: Lateral epicondylitis (tennis elbow) is a frequently reported condition. A wide variety of treatment strategies has been described. As of yet, no optimal strategy has been identified. OBJECTIVES: To assess the effectiveness of orthotic devices for the treatment of tennis elbow. SEARCH STRATEGY: We searched Medline, Embase, CINAHL, the Cochrane Controlled Trial Register, Current Contents up to May 1999 and reference lists from all retrieved articles. Experts on the subjects were approached for additional trials. SELECTION CRITERIA: All randomised clinical trials (RCT) describing individuals with diagnosed lateral epicondylitis and comparing the use of an orthotic device as a treatment strategy were evaluated for inclusion. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the validity of the included trials and extracted data on relevant outcome measures. Dichotomous outcomes were expressed as Relative Risks (RRs) and continuous outcomes as Standardised Mean Differences (SMD), both with corresponding 95% confidence intervals (95% CI). Statistical pooling and subgroup analyses were intended MAIN RESULTS: Five RCTs (N per group 7-49) were included. Validity score ranged from 3-9 positive items out of 11. Subgroup analyses were not performed due to the small number of trials. The limited number of included trials present few outcome measures and limited long-term results. Pooling was not possible due to large heterogeneity amongst trials. REVIEWER'S CONCLUSIONS: No definitive conclusions can be drawn concerning effectiveness of orthotic devices for lateral epicondylitis. More well-designed and well-conducted RCTs of sufficient power are warranted.

Conservative treatment of lateral epicondylitis: brace versus physical therapy or a combination of both-a randomized clinical trial.

BACKGROUND: The authors evaluated the effectiveness of brace-only treatment, physical therapy, and the combination of these for patients with tennis elbow. METHODS: Patients were randomized over 3 groups: brace-only treatment, physical therapy, and the combination of these. Main outcome measures were success rate, severity of complaints, pain, disability, and satisfaction. Data were analyzed using both intention-to-treat and per-protocol analyses. Follow-up was 1 year. RESULTS: A total of 180 patients were randomized. Physical therapy was superior to brace only at 6 weeks for pain, disability, and satisfaction. Contrarily, brace-only treatment was superior on ability of daily activities. Combination treatment was superior to brace on severity of complaints, disability, and satisfaction. At 26 weeks and 52 weeks, no significant differences were identified. CONCLUSION: Conflicting results were found. Brace treatment might be useful as initial therapy. Combination therapy has no additional advantage compared to physical therapy but is superior to brace only for the short term.

Arthroscopic treatment for osteochondral defects of the talus. Results at follow-up at 2 to 11 years.

We reviewed 38 patients who had been treated for an osteochondral defect of the talus by arthroscopic curettage and drilling. The indication for surgical treatment was persistent symptoms after conservative treatment for at least six months. A total of 22 patients had received primary surgical treatment (primary group) and 16 had had failed previous surgery (revision group). The mean follow-up was 4.8 years (2 to 11). Good or excellent results, as assessed by the Ogilvie-Harris score, were found in 86% in the primary group and in 75% in the revision group. Two further procedures were required, one in each group. Radiological degenerative changes were seen in one ankle in the revision group after ten years. Arthroscopic curettage and drilling are recommended for both primary and revision treatment of an osteochondral defect of the talus.

A double blind, randomised, parallel group study on the efficacy and safety of treating acute lateral ankle sprain with oral hydrolytic enzymes.

OBJECTIVE: To compare the effectiveness and safety of the triple combination Phlogenzym (rutoside, bromelain, and trypsin) with double combinations, the single substances, and placebo. DESIGN: Multinational, multicentre, double blind, randomised, parallel group design with eight groups structured according to a factorial design. SETTING: Orthopaedic surgery and emergency departments in 27 European hospitals. PARTICIPANTS: A total of 721 patients aged 16-53 years presenting with acute unilateral sprain of the lateral ankle joint. PRIMARY EFFICACY CRITERIA: (a) Pain on walking one or two steps, as defined by the patient on a visual analogue scale. (b) The range of motion, as measured by the investigator and expressed as a sum of flexion and extension. (c) The volume of the injured ankle measured with a volometer. RESULTS: At the primary end point at seven days, the greatest reduction in pain was in the bromelain/trypsin group (73.7%). The Phlogenzym group showed a median reduction of 60.3%, and the placebo group showed a median reduction of 73.3%. The largest increase in range of motion (median) was in the placebo group (60% change from baseline). The Phlogenzym group showed a median increase of 42.9%. The biggest decrease in swelling was in the trypsin group (3.9% change from baseline). The Phlogenzym group showed a -2.30% change from baseline and the placebo group a -2.90% change. In the subgroup analysis of patients who did not use a Caligamed brace, Phlogenzym was superior to placebo for the summarising directional test of the primary efficacy criteria (MW = 0.621; LB-CI 0.496; p = 0.029; one sided Wei-Lachin procedure). The vast majority of doctors and patients rated the tolerability of all treatments tested as very good or at least good. CONCLUSIONS: Phlogenzym was not found to be superior to the three two-drug combinations, the three single substances, or placebo for treatment of patients with acute unilateral sprain of the lateral ankle joint. The small subgroup of patients treated without the support of a Caligamed brace showed evidence of superiority of Phlogenzym over placebo. Further research is warranted to study this effect of Phlogenzym in patients treated without ankle support.

Treatment strategies in osteochondral defects of the talar dome: a systematic review.

The aim of this study was to investigate the results of different treatment strategies for osteochondral defects (OCD) of the talus. Electronic databases from 1966 to July 1998 were systematically screened. Based on our inclusion criteria 32 studies describing the results of treatment strategies for OCD of the talus were included. No randomized clinical trials (RCT's) were identified. Fourteen studies described the results of excision alone, 11 the results of (EC), 14 the results of (ECD), 1 the results of cancellous bone grafting after EC, 1 the results of osteochondral transplantation and 3 the results of fixation. The average success rate of non-operative treatment (NT) was 45%. Comparison of different surgical procedures shows that the average highest success rate was reached by excision, curettage and drilling (ECD) (85%) followed by excision and curettage (EC) (78%) and excision alone (38%). Based on this systematic review we conclude that NT and excision alone are not to be recommended in treating talar OCD. Both EC and ECD have been shown to lead to a high percentage good/excellent results. However, due to great diversity in the articles and variability in treatment results, no definitive conclusions can be drawn. Further prospective randomized controlled trials are required to compare the outcome of these two surgical strategies for OCD of the talus.

Radial head fractures: effectiveness of conservative treatment versus surgical intervention. A systematic review.

INTRODUCTION: Radial head fractures are common elbow fractures. The Mason classification is used to describe the fracture. As of yet, there is no consensus on optimal treatment strategy for Mason II-IV fractures. The aim of this study was to compare the results of conservative treatment with different surgical strategies for radial head fractures. MATERIALS AND METHODS: Electronic databases from 1966 to 2004 were screened. Based on our inclusion criteria, 24 studies, describing 825 patients, were included. RESULTS: For Mason type II fractures, residual pain was present in 42% of the conservatively treated of the patients compared to 32% of the surgically treated patients. Good/excellent results for Broberg score were 52 and 88%, respectively. For Mason type III and IV fractures, no conservatively treated patients were described. CONCLUSIONS: There is insufficient evidence to be able to draw definitive conclusions on optimal treatment of type II-IV radial head fractures. Evidence is currently limited to a maximum level II evidence. There is great need for sufficiently powered randomized controlled trials.

The predictive value of diagnostic sonography for the effectiveness of conservative treatment of tennis elbow.

OBJECTIVE: Tennis elbow is a common complaint. Several treatment strategies have been described, but an optimal strategy has not been identified. Sonographic imaging as a predictive factor has never been studied. The aim of our study was to determine the value of sonographic findings in predicting response to conservative therapy for tennis elbow. This was done in a randomized controlled trial in which the effectiveness of a brace only, physical therapy only, and a combination of both were compared. SUBJECTS AND METHODS: Patients with tennis elbow complaints were randomized. Sonography was performed before randomization in 57 patients. Outcome measures at 6 weeks' follow-up were success rate and decrease in pain (scale, 0-100). Data were analyzed using an intention-to-treat analysis. RESULTS: In only 75% of the imaged patients, sonographic abnormalities were identified and the clinical diagnosis could thus be confirmed. The following entities were identified: hypo- and hyperechogenicity, swelling, calcification, bursitis, enthesopathy, and tendinosis. The positive predictive value of sonography for the different entities varied between 0.78 and 0.82, and the negative predictive value ranged between 0.23 and 0.71. Predictive value was studied by subgroups of sonographic findings: hypoechoic, swelling present, enthesopathy, any entity present, and no entity present. We found no significant differences among the subgroups for either success rate (range, 40-54%) or mean decrease in pain (range, 16-28 percentage points). CONCLUSION: No predictive value of sonography for the detection of abnormalities was identified in this study. Its diagnostic capability showed limited value. However, limitations in this study necessitate drawing definitive conclusions with care.