Intra-articular Injections of the Hip and Knee With Triamcinolone vs Ketorolac: A Randomized Controlled Trial.

BACKGROUND: Clinicians commonly utilize intra-articular injections to treat symptomatic primary arthritis. Steroid injections are common yet have immune-modulating effects and can alter gene expression which may delay definitive arthroplasty and further damage cartilage. Nonsteroidal anti-inflammatory injections may offer a safer profile due to their differing mechanism of action; however, there is a relative dearth of information regarding their efficacy. This noninferiority study compares the effectiveness of triamcinolone vs ketorolac in treating symptoms of moderate to advanced primary osteoarthritis of the hip and knee. METHODS: In total, 110 patients (52 hips and 58 knees) with moderate to severe radiographic primary osteoarthritis of the hip or knee were randomized in a double-blinded study to receive an ultrasound-guided intra-articular injection of ketorolac or triamcinolone. Patient-reported outcome measures were collected pre-injection and at 1 week, 1 month, and 3 months. RESULTS: For hips and knees, intra-articular injections with either ketorolac or triamcinolone led to statistically significant improvements in patient-reported outcome measures. The treatment effect size was largest at 1 week and decreased over time. Primary analysis of variance comparisons revealed no significant differences between ketorolac and triamcinolone. For knee injections, post hoc secondary analysis suggests slight added durability in the triamcinolone group. Adverse effects were minimal with both interventions. CONCLUSION: Intra-articular ketorolac injections provide comparable improvement to triamcinolone for primary hip and knee osteoarthritis. Ketorolac is an additional low-cost option for conservative management of primary osteoarthritis, and due to its differing mechanism of action, it may not propagate additional cartilage damage or preclude from early surgical intervention if unsuccessful. TRIAL REGISTRATION NUMBER: NCT04441112.

Chest Trauma in Athletic Medicine.

While overall sports participation continues at high rates, chest injuries occur relatively infrequently. Many conditions of chest injury are benign, related to simple contusions and strains, but the more rare, severe injuries carry a much higher risk of morbidity and mortality than the typical issues encountered in athletic medicine. Missed or delayed diagnosis can prove to be catastrophic. Sports medicine providers must be prepared to encounter a wide range of traumatic conditions relating to the torso, varying from the benign chest wall contusion to the life-threatening tension pneumothorax. Basic field-side management should be rapid and focused, using the standardized approach of Advanced Traumatic Life Support protocol. Early and appropriate diagnosis and management can help allow safe and enjoyable sports participation.

Derivation of a Performance Checklist for Ultrasound-Guided Arthrocentesis Using the Modified Delphi Method.

OBJECTIVES: Arthrocentesis is an important skill for physicians in multiple specialties. Recent studies indicate a superior safety and performance profile for this procedure using ultrasound guidance for needle placement, and improving quality of care requires a valid measurement of competency using this modality. METHODS: We endeavored to create a validated tool to assess the performance of this procedure using the modified Delphi technique and experts in multiple disciplines across the United States. RESULTS: We derived a 22-item checklist designed to assess competency for the completion of ultrasound-guided arthrocentesis, which demonstrated a Cronbach's alpha of 0.89, indicating an excellent degree of internal consistency. CONCLUSIONS: Although we were able to demonstrate content validity for this tool, further validity evidence should be acquired after the tool is used and studied in clinical and simulated contexts.

The chiropractic care of children.

OBJECTIVE: The objective of this study was to characterize the practice of pediatric chiropractic. DESIGN: The study design was a cross-sectional descriptive survey. SETTINGS/LOCATION: The settings were private practices throughout the United States, Canada, and Europe. PARTICIPANTS: The participants were 548 chiropractors, the majority of whom are practicing in the United States, Canada, and Europe. MAIN OUTCOME MEASURES: Practitioner demographics (i.e., gender, years in practice, and chiropractic alma mater), practice characteristics (i.e., patient visits per week, practice income reimbursement), and chiropractic technique were surveyed. The practitioners were also asked to indicate common indicators for pediatric presentation, their practice activities (i.e., use of herbal remedies, exercise and rehabilitation, prayer healing, etc.), and referral patterns. RESULTS: A majority of the responders were female with an average practice experience of 8 years. They attended an average of 133 patient visits per week, with 21% devoted to the care of children (<18 years of age). Practice income was derived primarily from out-of-pocket reimbursement with charges of an average of $127 and $42 for the first and subsequent visits, respectively. These visits were reimbursed to address common conditions of childhood (i.e., asthma, ear infections, etc.). Approach to patient care was spinal manipulative therapy (SMT) augmented with herbal remedies, exercises, rehabilitation, and so on. Wellness care also figured prominently as a motivator for chiropractic care. Fifty-eight percent (58%) indicated an established relationship with an osteopathic or medical physician. Eighty percent (80%) of the responders indicated referring patients to medical practitioners while only 29% indicated receiving a referral from a medical/osteopathic physician. CONCLUSIONS: The chiropractic care of children is a significant aspect of the practice of chiropractic. Further research is warranted to examine the safety and effectiveness of this popular nonallopathic approach to children's health.

The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practice-based research network.

BACKGROUND: With continued popularity of complementary and alternative medicine (CAM) therapies for children, their safety and effectiveness are of high concern for both CAM and conventional therapy providers. Chiropractic is the most popular form of practitioner-based CAM therapies for children. OBJECTIVE: The objective of this study was to describe the practice of pediatric chiropractic, including its safety and effectiveness. DESIGN: This study used a cross-sectional survey. SETTING: A practice-based research network was used for this study. PATIENTS/PARTICIPANTS: Participants were chiropractors and parents of pediatric patients (aged < or =18 years) attending chiropractic visits ranging from one to 12 visits. INTERVENTION: This is a survey study. No interventions were rendered in the completion of this study. MAIN OUTCOME MEASURES: Demographics, clinical presentations, treatment-associated aggravations, complications and improvements. RESULTS: The indicated primary reason for chiropractic care of children was "wellness care." With respect to condition-based presentations, musculoskeletal conditions were the most common, in addition to nonmusculoskeletal conditions of childhood. The most common techniques used were diversified technique, Gonstead technique, Thompson technique, and activator methods. Treatment-associated complications were not indicated by the chiropractic and parent responders. Chiropractor responders indicated three adverse events per 5,438 office visits from the treatment of 577 children. The parent responders indicated two adverse events from 1,735 office visits involving the care of 239 children. Both sets of responders indicated a high rate of improvement with respect to the children's presenting complaints, in addition to salutary effects unrelated to the children's initial clinical presentations.