Outcomes Using Focused Shockwave for Treatment of Bone Stress Injury in Runners.

Bone stress injury (BSI) is a common overuse injury that can result in prolonged time away from sport. Limited studies have characterized the use of extracorporeal shockwave therapy (ESWT) for the treatment of BSI. The purpose of this study was to describe the use of ESWT for the management of BSI in runners. A retrospective chart review was performed to identify eligible patients in a single physician's clinic from 1 August 2018 to 30 September 2022. BSI was identified in 40 runners with 41 injuries (28 females; average age and standard deviation: 30 ± 13 years; average pre-injury training 72 ± 40 km per week). Overall, 63% (n = 26) met the criteria for moderate- or high-risk Female or Male Athlete Triad categories. Runners started ESWT at a median of 36 days (IQR 11 to 95 days; range 3 days to 8 years) from BSI diagnosis. On average, each received 5 ± 2 total focused ESWT treatments. Those with acute BSI (ESWT started <3 months from BSI diagnosis) had an average return to run at 12.0 ± 7.5 weeks, while patients with delayed union (>3 months, n = 3) or non-union (>6 months, n = 9) had longer time for return to running (19.8 ± 14.8 weeks, p = 0.032). All runners returned to pain-free running after ESWT except one runner with non-union of grade 4 navicular BSI who opted for surgery. No complications were observed with ESWT. These findings suggest that focused ESWT may be a safe treatment for the management of BSI in runners.

Do Adolescent Idiopathic Scoliosis Patients With Vitamin D Deficiency Have Worse Spine Fusion Outcomes?

BACKGROUND: Prior research has shown that patients with adolescent idiopathic scoliosis (AIS) have a higher prevalence of vitamin D deficiency compared with healthy peers. In adult orthopaedic populations, vitamin D deficiency has been shown to be a risk factor for higher reported pain and lower function. We investigated whether there was an association between vitamin D levels and AIS patient-reported outcomes, as measured by the Scoliosis Research Society (SRS-30) questionnaire. METHODS: This was a single-center, cross-sectional study. Postoperative AIS patients were prospectively recruited during routine follow-up visits, 2 to 10 years after spine fusion. Vitamin D levels were measured by serum 25-hydroxyvitamin D (ng/mL). Patients were categorized based on vitamin D level: deficient (<20 ng/mL), insufficient (20 to 29 ng/mL), or sufficient (≥30 ng/mL). The correlation between vitamin D levels and SRS-30 scores was analyzed using multivariable analysis and pair-wise comparisons using Tukey method. RESULTS: Eighty-seven AIS patients (83% female) were enrolled who presented at median 3 years (interquartile range: 2 to 5 y; range: 2 to 10 y) after spine fusion. Age at time of surgery was mean 15 (SD±2) years. Major coronal curves were a mean of 57 (SD±8) degrees preoperatively and 18 (SD±7) degrees postoperatively. It was found that 30 (34%) of patients were vitamin D sufficient, 33 (38%) were insufficient, and 24 (28%) were deficient. Although there was no correlation between vitamin D level and Pain, Mental Health, or Satisfaction domains ( P >0.05), vitamin D-deficient patients were found to be younger ( P <0.001) and had lower SRS-30 function ( P =0.002), Self-image ( P <0.001), and total scores ( P =0.003). CONCLUSIONS: AIS patients with vitamin D deficiency (<20 ng/mL) are more likely to be younger age at time of surgery, and report lower Function, Self-image, and Total SRS-30 scores postoperatively. Further work is needed to determine whether vitamin D supplementation alters curve progression and patient outcomes. LEVEL OF EVIDENCE: Level II-prognostic study.

Bracing for juvenile idiopathic scoliosis: retrospective review from bracing to skeletal maturity.

BACKGROUND: Juvenile idiopathic scoliosis (JIS) outcomes with brace treatment are limited with poorly described bracing protocols. Between 49 and 100% of children with JIS will progress to surgery, however, young age, long follow-up, and varying treatment methods make studying this population difficult. The purpose of this study is to report the outcomes of bracing in JIS treated with a Boston brace™ and identify risk factors for progression and surgical intervention. METHODS: This is a single-center retrospective review of 175 patients with JIS who initiated brace treatment between the age of 4 and 9 years. A cohort of 140 children reached skeletal maturity; 91 children had surgery or at least 2 year follow-up after brace completion. Standard in-brace protocol for scoliosis 320° was a Boston brace for 18-20 h/day after MRI (n = 82). Family history, MRI abnormalities, comorbidities, curve type, curve magnitude, bracing duration, number of braces, compliance by report, and surgical interventions were recorded. RESULTS: Children were average 7.9 years old (range 4.1-9.8) at the initiation of bracing. The Boston brace™ was prescribed in 82 patients and nine used night bending brace. Mid-thoracic curves (53%) was the most frequent deformity. Maximum curve at presentation was on average 30 ± 9 degrees, in-brace curve angle was 16 ± 8 degrees, and in-brace correction was 58 ± 24 percent. Patients were braced an average of 4.6 ± 1.9 years. 61/91 (67%) went on to posterior spinal fusion at 13.3 ± 2.1 (range 9.3-20.9) years and curve magnitude of 61 ± 12 degrees. Of those that underwent surgery, 49/55 (86%) progressed > 10°, 6/55 (11%) stabilized within 10°, and 0/55 (0%) improved > 10° with brace wear. No children underwent growth-friendly posterior instrumentation. Of the 28 who did not have surgical correction, 3 (11%) progressed > 10°, 13/28 (46%) stabilized within 10°, and 12/28 (43%) improved > 10° with brace wear. CONCLUSIONS: This large series of JIS patients with bracing followed to skeletal maturity with long-term follow-up. Surgery was avoided in 33% of children with minimal to no progression, and no child underwent posterior growth-friendly constructs. Risk factors of needing surgery were noncompliance and larger curves at presentation.

Knee osteoarthritis in midlife women: unique considerations and comprehensive management.

OBJECTIVE: Knee osteoarthritis (KOA) is a common musculoskeletal condition that particularly afflicts women in menopause. The purpose of this review is to describe the pathophysiology and treatment considerations for this subset of the population. METHODS: Medline/PubMed indexed articles related to the pathophysiology, diagnosis, and management of osteoarthritis were included in this narrative review. RESULTS AND CONCLUSION: Menopause has a multitude of effects that affect KOA, including hormonal shifts; loss of bone mineral density, muscle mass, and tendon strength; and changes to pain perception. Here, we discuss how a practitioner can assess the factors that are known to worsen KOA symptoms, including postural (spine, pelvic, and knee) alignment and functional muscle strength. The development of an effective exercise program is at the forefront of management. Optimizing other lifestyle factors including nutrition and sleep are particularly important in this patient population. Sleep disturbance from vasomotor symptoms can also increase perception of knee pain, for which pharmacologic options such as gabapentin or duloxetine may be pursued. In total, these interventions have large ramifications in decreasing pain and increasing function through improved range of motion, body composition, and walking speed in women with KOA.

Vitamin D levels and pain outcomes in adolescent idiopathic scoliosis patients undergoing spine fusion.

PURPOSE: Prior research has indicated adolescent idiopathic scoliosis (AIS) patients have lower bone mineral density and lower vitamin D levels than healthy peers. Vitamin D deficiency has been associated with higher levels of pain. This study investigated whether vitamin D-deficient AIS patients had higher pain before or immediately after posterior spine fusion (PSF) surgery. METHODS: 25-Hydroxy vitamin D levels were tested in all AIS patients at their pre-operative appointment. Patients were grouped by serum 25-hydroxy vitamin D level: deficient, < 20 ng/mL; insufficient, 20-29 ng/mL; sufficient, ≥ 30 ng/mL. Primary outcomes included pre-operative Scoliosis Research Society Health-Related Quality of Life (SRS-30) and numeric rating scale (NRS) scores (0-10) up to 72 h post-operatively, and analyzed using ANOVA and linear mixed modeling, respectively. 176 patients undergoing PSF were included. Intra-operative characteristics by vitamin D status were also assessed. The cohort was 82% female and an average of 15.2 years (range 10.6-25.3 years) at fusion. Average major curve was 60 (range 40-104) degrees pre-operatively. RESULTS: Forty-five (26%) patients were deficient in vitamin D, 75 (43%) were insufficient, and 56 (32%) were sufficient. Patients with vitamin D deficiency had lower average household income by zip code (p < 0.01) and higher secondhand smoke exposure (p < 0.001). There were no differences in pre-operative SRS-30 score, pre- and post-operative major curve angles, or estimated blood loss across vitamin D groups. Trajectories of NRS indicated no differences in pain during the first 72 h after surgery. CONCLUSION: Vitamin D deficiency in this population is associated with potential markers of lower socioeconomic status; however, it does not influence AIS PSF patients' experience of pain before or immediately after spine fusion surgery. LEVEL OF EVIDENCE: II.