Externally validated treatment algorithm acceptably predicts nonoperative treatment success in patients with anterior cruciate ligament rupture.

PURPOSE: This study aims to develop and externally validate a treatment algorithm to predict nonoperative treatment success or failure in patients with anterior cruciate ligament (ACL) rupture. METHODS: Data were used from two completed studies of adult patients with ACL ruptures: the Conservative versus Operative Methods for Patients with ACL Rupture Evaluation study (development cohort) and the KNee osteoArthritis anterior cruciate Ligament Lesion study (validation cohort). The primary outcome variable is nonoperative treatment success or failure. Potential predictor variables were collected, entered into the univariable logistic regression model and then incorporated into the multivariable logistic regression model for constructing the treatment algorithm. Finally, predictive performance and goodness-of-fit were assessed and externally validated by discrimination and calibration measures. RESULTS: In the univariable logistic regression model, a stable knee measured with the pivot shift test and a posttrauma International Knee Documentation Committee (IKDC) score <50 were predictive of needing an ACL reconstruction. Age >30 years and a body mass index > 30 kg/m2 were predictive for not needing an ACL reconstruction. Age, pretrauma Tegner score, the outcome of the pivot shift test and the posttrauma IKDC score are entered into the treatment algorithm. The predictability of needing an ACL reconstruction after nonoperative treatment (discrimination) is acceptable in both the development and the validation cohort: area under the curve = resp. 0.69 (95% confidence interval [CI]: 0.58-0.81) and 0.68 (95% CI: 0.58-0.78). CONCLUSION: This study shows that the treatment algorithm can acceptably predict whether an ACL injury patient will have a(n) (un)successful nonoperative treatment (discrimination). Calibration of the treatment algorithm suggests a systematical underestimation of the need for ACL reconstruction. Given the limitations regarding the sample size of this study, larger data sets must be constructed to improve the treatment algorithm further. LEVEL OF EVIDENCE: Level II.

Reverse shoulder arthroplasty or nothing for patients with displaced proximal humeral fractures: a randomized controlled trial.

BACKGROUND: The benefits of reverse shoulder arthroplasty compared to nonoperative treatment for patients presenting with complex proximal fractures have been rarely explored. The aim of this prospective study was to compare the functional results of reverse shoulder arthroplasty with those of nonsurgical treatment in patients with displaced proximal humeral fractures. METHODS: A multicentric prospective randomized control trial of patients older than 70 years who sustained an acute proximal humeral fracture (3 or 4 parts), with less than 3 weeks of evolution, and had no previous condition or surgery on the affected shoulder was conducted. Patients were randomly assigned to the intervention group (implantation of a reverse shoulder arthroplasty and tuberosities reattachment) or the control group (nonoperative treatment). Functional outcome was assessed using the Constant-Murley score (CMS) at the 1-year follow-up. Complications and reinterventions were considered secondary outcomes. The power of the study relied on the inclusion of 81 patients to recognize a statistically significant difference of 10 points between CMS scores in the groups. Analysis was performed based on the intention to treat principle. RESULTS: Eighty-one patients were randomized to surgical treatment or nonoperative treatment, while 66 patients completed the 1-year follow-up evaluation. There was no significant difference between the groups in terms of age (76.1 yo vs. 77.43 yo, P = .43), sex (81.08% women in the surgical group vs. 84.09% in the nonoperative group, P = .72), or type of fracture according to Neer's classification system (P = .06). At the 1-year follow-up, the group assigned to undergo the intervention had better functional outcomes than the nonoperative treatment group (mean CMS; 61.24, SD: 13.33 vs. mean CMS: 52.44, SD: 16.22, P: .02), with a mean difference of 8.84 points, 95% CI (1.57, 16.11). Two patients in the intervention group (6.5%) suffered major complications (periprosthetic joint infection and axillary nerve palsy). No major complications were observed in the nonoperative group. One patient in the intervention group underwent secondary surgery for a periprosthetic joint infection. CONCLUSIONS: Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture. The difference in CMS is close to the clinically significant thresholds, and some harms are associated with the operative treatment.

Delayed debridement affects prognosis in patients with purulent flexor tenosynovitis: a retrospective cohort and multivariate analyses.

INTRODUCTION: Purulent flexor tenosynovitis (PFT) is a severe condition, and many patients report serious postoperative complications such as amputation, limited range of motion (ROM), or recurrence of symptoms. However, the ideal protocol for PFT treatment remains unknown owing to the limited number of studies. This retrospective cohort study aimed to identify prognostic factors for PFT treatment outcomes. MATERIALS AND METHODS: Sixty-six patients (46 men and 20 women) with PFT who underwent surgical debridement at our hospital between September 2005 and January 2023 were included in this study. We conducted multivariate linear regression analysis with permanent deficit as the primary outcome. We defined the number of operations, laboratory data, interval from onset to debridement, previous conservative treatment, aetiology, Kanavel's signs, and medical history of diabetes mellitus as possible prognostic factors. We also defined the interval from onset to debridement as a secondary outcome and performed logistic regression analysis. RESULTS: Overall, 25 (38%) patients had postoperative deficits. Longer interval from onset to surgery (odds ratio [OR]: 1.1, 95% confidence interval [CI]: 1.0-1.1) and polymicrobial infection (OR: 7.8, 95% CI: 1.56-38.8) were significant prognostic factors for unfavourable outcomes. Additional multivariate analysis showed that preoperative conservative treatment prolonged the interval to surgery (estimate, 16.4; standard error, 1.6; p < 0.05). CONCLUSIONS: The results of this study suggest that indications for nonoperative treatment of PFT are limited and that earlier surgical debridement is recommended.

No difference in clinical outcomes between operative and nonoperative management of minimally retracted proximal hamstring ruptures.

PURPOSE: The indications for surgical treatment of proximal hamstring ruptures are continuing to be refined. The purpose of this study was to compare patient-reported outcomes (PROs) between patients who underwent operative or nonoperative management of proximal hamstring ruptures. METHODS: A retrospective review of the electronic medical record identified all patients who were treated for a proximal hamstring rupture at our institution from 2013 to 2020. Patients were stratified into two groups, nonoperative or operative management, which were matched in a 2:1 ratio based on demographics (age, gender, and body mass index), chronicity of the injury, tendon retraction, and number of tendons torn. All patients completed a series of PROs including the Perth Hamstring Assessment Tool (PHAT), Visual Analogue Scale for pain (VAS), and the Tegner Activity Scale. Statistical analysis was performed using multi-variable linear regression and Mann-Whitney testing to compare nonparametric groups. RESULTS: Fifty-four patients (mean age = 49.6 ± 12.9 years; median: 49.1; range: 19-73) with proximal hamstring ruptures treated nonoperatively were successfully matched 2:1 to 27 patients who had underwent primary surgical repair. There were no differences in PROs between the nonoperative and operative cohorts (n.s.). Chronicity of the injury and older age correlated with significantly worse PROs across the entire cohort (p < 0.05). CONCLUSIONS: In this cohort of primarily middle-aged patients with proximal hamstring ruptures with less than three centimeters of tendon retraction, there was no difference in patient-reported outcome scores between matched cohorts of operatively and nonoperatively managed injuries. LEVEL OF EVIDENCE: Level III.

Blunt Abdominal Trauma in Children: A Review of 105 Cases.

Aims: The aim of the study is to identify the epidemiological, diagnostic, therapeutic, and evolutionary characteristics of patients admitted for blunt abdominal trauma (BAT) in a level 3 children's hospital. Results: The frequency was 13.1 cases/year. The mean age was 6.6 years. The sex ratio was 3.56. Road traffic accidents were the most frequent cause (54.3%). Abdominal tenderness (88.6%) was the most common physical sign. Associated lesions were found in 40% of cases. Abdominal sonography (85.7%) was the most common imaging tool followed by an abdominal computed tomography scan (34.4%). The liver was the most affected organ (24.7%) and contusion was the most frequent lesion (65.4%). The majority of patients had received nonoperative treatment (93.3%). The average length of hospitalization was 5.6 days. The outcome in all cases was favorable. No mortality was reported. Conclusions: BAT in children is common in boys under the age of 10. They are caused by road accidents. Physical examination combined with abdominal ultrasound is very important in the therapeutic decision, which in most cases is a conservative one. Morbidity and mortality are almost nil.

Implementing Nonoperative Treatment Strategy for Simple Pediatric Appendicitis: A Qualitative Study.

INTRODUCTION: A nonoperative treatment strategy (NOT) with antibiotics for children with simple appendicitis could reduce anesthesia and surgery-related complications. As the implementation of a new treatment in routine clinical practice may take years, this study aims to identify barriers and facilitators for implementation of NOT for children with simple appendicitis. MATERIALS AND METHODS: To identify barriers and facilitators for its implementation, we conducted 14 semistructured interviews and a focus group with health insurance/hospital policymakers, surgical clinicians, and young people-together with their parents-who have been treated surgically or with antibiotics. Transcripts were open coded and categorized as per the framework for healthcare innovations by Fleuren et al. RESULTS: We identified four main themes: (1) Appendicitis is a well-known disease. Children, parents, and clinicians regard appendectomy as routine and safe, making them reluctant toward other treatment options. (2) Clinicians regard uptake of NOT in the national appendicitis guideline necessary for its implementation. (3) For identification of patients best suited for NOT more experience and scientific evidence is needed. (4) Appendectomy and NOT have different risk and benefits making the treatment choice depended on individual patient preferences. CONCLUSIONS: By addressing how NOT and operative treatment are regarded by patients and surgeons could have a substantial impact on the implementation of NOT for children with simple appendicitis. Furthermore, the individual preferences of patients need to be taken into account when choosing between operative and NOT. In other words, offering NOT in a shared decision-making model seems the first appropriate step in its implementation.

Treatment of Flexion Instability After Primary Total Knee Arthroplasty: Operative and Nonoperative Management of 218 Cases.

BACKGROUND: For patients with flexion instability, there is a paucity of literature on the effectiveness of nonoperative management, and series on revision TKAs are limited. The purpose of this study is to evaluate effectiveness and prognostic factors of nonoperative management of flexion instability, and report survivorship, clinical outcomes, and radiographic results after revision TKA for flexion instability. METHODS: We identified 218 patients with flexion instability after primary TKA through our total joint registry between 1990 and 2019. Mean age was 66 years, 59% were women, and 58% had a cruciate-retaining (CR) implant. Initially, 152 patients (70%) were treated nonoperatively. First-time revision TKA was ultimately performed in 173 patients. Kaplan-Meier survivorship was calculated. Knee Society Scores and radiographs were reviewed. Mean follow-up was 6 years. RESULTS: Of the 152 patients treated nonoperatively, 66% reported no improvement. Patients with a CR design (hazard ratio [HR] 3.3, P < .001), inflammatory arthritis (HR 1.6, P = .03), smokers (HR 2.1, P = .04), and patient-reported instability (HR 3.8, P < .001) or effusions (HR 3.5, P < .001) were more likely to undergo revision. Of the 173 revised, the 10-year survivorship free of any re-revision was 87% with recurrent flexion instability (7), global instability (3), and infection (3) being most common. Knee Society Scores improved from 50 to 65 (P = .14). At final follow-up, all implants were well-fixed. CONCLUSION: In this large series of flexion instability after primary TKA, nonoperative management led to improvement in one third. Patients with a CR design or with patient-reported instability and/or effusions were most likely to undergo revision. Revision TKA demonstrated modest 10-year functional improvements and good survivorship. LEVEL OF EVIDENCE: IV (retrospective), Therapeutic.

Drivers of Unequal Healthcare Costs in the Nonoperative Treatment of Late-Stage Knee Osteoarthritis Prior to Primary Total Knee Arthroplasty.

BACKGROUND: In the United States, patients with late-stage knee osteoarthritis (OA) often undergo several nonoperative treatments and related procedures prior to total knee arthroplasty. The costs of these treatments and procedures are substantial, and the variation in healthcare costs among different groups of patients may exist. The purpose of this study is to examine these costs and determine the drivers of costs in patients with the highest healthcare expenditure. METHODS: An observational cohort study was conducted using the IBM Watson Health MarketScan databases from January 1, 2017 to December 31, 2019. The primary outcome was the cost of payments for nonoperative procedures which included (i) physical therapy (PT), (ii) bracing, (iii) intra-articular injections: professional fee, hyaluronic acid (IA-HA), and corticosteroids (IA-CS), (iv) medication: nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and acetaminophen, and (v) knee-specific imaging. RESULTS: Among the 24,492 patients included in the study, the total payments per patient for nonoperative care were $3,735 ± 3,049 in the highest payment quartile (Q4) and $137 ± 70 in the lowest payment quartile (Q1). Per-patient-per-month costs generally increased across quartiles for procedures. Comparing Q4 to Q1, the largest changes in prevalence were found in IA-HA (348×), bracing (10×), and PT (7×). Patients who were prescribed IA-HA and PT had a 28.3-times and 4.8-times greater likelihood, respectively, to be a higher-paying patient. CONCLUSION: Unequal healthcare costs in the nonoperative treatment of late-stage knee OA are driven by differences in prevalent management strategies. Overall healthcare expenditure may be reduced if only guideline-concordant treatments are used.

Short-term outcome of double-shelled braces in neuromuscular scoliosis.

INTRODUCTION: Scoliosis in patients with neuromuscular disease is a common issue and leads to secondary impairment. It is thus important to help such patients to regain and retain best possible stability to improve their quality of life. One option is the double-shelled brace (DSB). The aim of this study was to provide information on the degree of correction when using a DSB on patients with neuromuscular scoliosis. METHODS: We included patients with neuromuscular scoliosis treated with double-shelled braces in this retrospective study. Radiographs of the full spine were taken with and without the DSB, the Cobb angles were measured and compared. The correction was expressed in percent of the lumbar and thoracic Cobb angles. In addition, compounding factors such as age, sex, type of the curves, and movement disorder were included. RESULTS: We analyzed data from 84 patients with scoliosis with different neuromuscular disorders. The mean age was 12.3 years (± 5.9). In the lumbar spine we detected an improvement of 27.5% (SD ± 32.9), in the thoracic spine 25.3% (SD ± 38.0). INTERPRETATION: Short-term corrections with a double-shelled brace in neuromuscular scoliosis present an average improvement of one fourth of the lumbar and thoracic Cobb angles and, independent of age, sex, movement disorder, shape or type of the curve. Only spasticity has an influence on the lumbar scoliosis outcome.

Splinting for the treatment of pediatric trigger thumbs: a pilot study.

Controversy still exists whether conservative treatment may be a useful option for the treatment of pediatric trigger thumbs. We reviewed a random sample patient cohort with regard to success rates depending on whether flexible or fixed trigger thumbs were present. We performed a pilot study of 13 children (15 thumbs), who received a standardized treatment protocol including a custom-made thermoplastic splint for use during sleeping hours for a minimum of 3 months. Splinting was of only minor value for moderate and severe cases was but was beneficial for the majority of patients showing triggering symptoms only. It may thus be a reasonable option to delay surgery in infants with mild/flexible cases.

The Acute Achilles Tendon Rupture: An Evidence-Based Approach from the Diagnosis to the Treatment.

Background and Objective: Acute Achilles tendon rupture (AATR) is a common injury with a significant impact on daily living. Although various systematic reviews and meta-analyses have been written on the topic, no actual consensus exists on the best treatment. We aimed to collect the highest quality of evidence on the subject and to produce a document to which to refer, from the diagnosis to the final treatment. Material and Methods: Inclusion criteria were systematic reviews discussing Achilles tendon rupture, concerning either diagnostic criteria, classification, or treatment; English language; clearly stated inclusion and exclusion criteria for patients' selection. Results: Thirteen systematic reviews were included in the study. A strong consensus exists about the higher risk of re-rupture associated with non-operative treatment and a higher risk of complications associated with surgical repair. Conclusions: The combination of minimally invasive repair and accelerated functional rehabilitation seems to offer the best results in the treatment of Achilles tendon rupture.

Nonoperative treatment of chronic, massive irreparable rotator cuff tears: a systematic review with synthesis of a standardized rehabilitation protocol.

PURPOSE: A massive, irreparable rotator cuff tear may cause significant pain and dysfunction. However, the efficacy of nonoperative treatment modalities in this subset of patients is not currently well known. Also, there is currently no gold standard nonoperative protocol to guide treatment. The goal of the present systematic review is to determine if there is any evidence to support the use of various nonoperative treatment modalities and synthesize a standardized nonoperative treatment protocol for the patient with a massive irreparable rotator cuff tear. METHODS: A comprehensive review of the literature utilizing PRISMA guidelines was performed. Studies involving clinical outcomes of nonoperative treatment of massive, irreparable rotator cuff tears were included. Articles were reviewed by 2 reviewers to determine inclusion or exclusion based on established criteria. Selected articles were reviewed for results of clinical and functional outcomes. The studies were also reviewed to determine their level of evidence and potential sources of bias. A standardized nonoperative treatment protocol was developed by taking described elements of the protocols used in studies that demonstrated clinical improvement beyond the MCID for the outcome scores used by the authors. RESULTS: A total of 10 studies met inclusion criteria for our studies. Of the included studies, 1 was Level III evidence and the remaining 9 were Level IV evidence. Multiple studies showed significant improvement exceeding the MCID for functional outcome scores following treatment. Also, several studies demonstrated significant improvements in strength and range of motion. The overall success of nonoperative treatment ranged from 32%-96%. The synthesized nonoperative treatment protocol is characterized by requiring some supervised physical therapy, often requiring 12 weeks or more, focusing on supine exercises with gradual progression to upright. Corticosteroid injections and nonsteroidal anti-inflammatory drugs may also be of benefit. CONCLUSION: Despite low-quality evidence, nonoperative treatment has been shown to be efficacious for patients with chronic, massive, irreparable rotator cuff tears. Using these results, a synthesized rehabilitation program was developed to guide clinicians when treating patients with massive irreparable rotator cuff tears.

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.

Long-term Natural Course of the Osteochondral Lesion of the Talus in a Child: A Case Report.

Recent reports have described midterm natural courses of osteochondral lesion of the talus (OLT) and lack of progression of ankle osteoarthritis (OA) in adult patients. The relationship between the OLT managed with nonoperative treatment and development of OA in children remains unknown. We report the long-term course of medial OLT in a 12-year-old female who was treated nonoperatively for 10 years. Radiographically, no osteoarthritic changes were observed at the first examination. She initially returned to her basketball club after nonoperative treatment. Although daily activities were not restricted, limitation of recreational activities began to appear at 4 years of follow-up. Subsequently, plain radiographs revealed bone absorption around the osteochondral fragment and osteophyte formation at the medial gutter, then ankle OA was advanced at the final follow-up.

[Characteristics and Significance of Gene Expression Changes in Peripheral Blood of Lumbar Disc Extrusion Patients before and after Nonoperative Treatment].

OBJECTIVE: To define the gene expression characteristics in the peripheral blood of patients with lumbar disc extrusion (LDE) and the effect of nonoperative treatment on the gene expression. METHODS: DNA microarray was used to identify semi-quantitatively the differentially expressed genes (DEGs) in the peripheral blood of patients with LDE and that of the healthy controls and the variation trend of these DEGs after nonoperative treatment. Enrichment analysis was done to reveal the functional characteristics of these DEGs, and network analysis was done to identify key genes that contribute to gene dysregulation. The levels of these key genes were measured by qRT-PCR to examine their expression in LDE patients and the controls, and the effect of nonoperative treatment on the expression level. RESULTS: We identified 153 DEGs in the peripheral blood of LDE patients and healthy controls, including 131 upregulated genes and 22 downregulated genes. Enrichment analysis revealed that most of the DEGs were related to immunity and the inflammatory response. Network analysis revealed that toll-like receptor 4 ( TLR4 ), matrix metallopeptidase 9 ( MMP9) and myeloperoxidase ( MPO), cathelicidin antimicrobial peptide ( CAMP), resistin ( RETN), toll-like receptor 5 ( TLR5) were the key genes in the protein-protein interaction network. These key genes were all enriched into the terms releated to immunity and the inflammatory response. The patients experienced pain relief after nonoperative treatment. Among the 153 DEGs, TLR5 , interleukin 1 receptor antagonist ( IL1 RN) and solute carrier family 8 member A1 ( SLC8 A1) were downregulated after nonoperative treatment. qRT-PCR revealed that the levels of TLR4, MMP9 , MPO, CAMP, RETN, TLR5, IL1 RN and SLC8 A1 in the peripheral blood of the LDE patients were higher than those of the healthy control group ( P<0.05). In addition, TLR5 , IL1 RN and SLC8 A1 expression levels decreased after treatmentin in comparison with the levels before treatment ( P<0.05). CONCLUSION: Gene expression in the peripheral blood of LDE patients was characterized by the dysregulation of immune and inflammatory response-related genes, among which, TLR4, MMP9, MPO, CAMP, RETN and TLR5, the genes relevant to immune and inflammatory response, played a key role in the dysregulation of gene expression in the peripheral blood of LDE patients. The outcome of non-operative treatment may be related to the downregulation of the overexpressed TLR5, IL1 RN and SLC8 A1 in the peripheral blood of patients.

Long-term outcomes and complications associated with operative and nonoperative treatment of distal radius fractures. Do we need to restore anatomy to have satisfactory clinical outcome?

A i m: The aim of this study was to assess long-term outcomes and complications associated with conservative and operative treatment of distal radius fractures and to determine if restoration of radio- graphic parameters influences functional outcomes. I n t r o d u c t i o n: Distal radius fractures (DRFs) are common injuries associated with many complications. Numerous studies suggest that operative treatment with anatomic reduction and restoration of radiographic parameters leads to better functional outcomes than nonsurgical treatment.Materials and Methods: We enrolled 207 patients with isolated DRF (mean age 64 ± 17.9 years, women 150 (72.5%)) to our retrospective, single-center study (101 treated operatively, 106 treated non-operatively). There were no significant differences in sex, age, AO type fracture between study groups. After 3.9 ± 1.6 years (mean ± SD) clinical, functional and radiological assessment was conducted using Disabilities of the Arm, Shoulder and Hand (DASH), Patient Rated Wrist Evaluation (PRWE), 9-Hole Peg Test (9-HPT), grip and pinch strength tools. R e s u l t s: We found higher rates of malunion in nonoperative group (p <0.0001) and worse radiologic parameters such as volar tilt (p <0.0001), teardrop angle (p <0.0001) versus operative cohort. Nevertheless radiological parameters were not correlated with DASH and PRWE results. Moreover, patients aged 50 years and above treated operatively had similar functional outcomes (DASH, PRWE) to those treated nonoperatively. C o n c l u s i o n s: Restoration of anatomic and thus radiologic parameters of radius may not be obligatory to achieve satisfactory functional outcome in patients with DRF aged 50 years or above. Patient is the most important 'factor' in determining appropriate and successful treatment method of distal radius fractures.

Outcomes of Nonsurgical Treatments for Symptomatic Adult Degenerative Scoliosis: A Systematic Review.

OBJECTIVE: To evaluate the effectiveness of nonsurgical treatments in symptomatic adult degenerative scoliosis (ADS). DESIGN: A systematic literature review. METHODS: PubMed, Web of Science, and The Cochrane Library were searched to identify research published since 1988. Randomized controlled trials (RCTs) and observational cohort studies were eligible if they featured symptomatic ADS patients aged ≥50 who received nonsurgical treatment. Minimum follow-up was six weeks, and outcomes of interest were pain, disability, quality of life, and Cobb angle. Evidence quality per intervention was rated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS: Six studies were included. Of these, four focused specifically on injections, bracing, or yoga; two involved multiple treatments. One RCT provided evidence for greater effectiveness of transforaminal epidural steroid injection over anesthetic alone in reducing radiating pain and disability. Two single-group retrospective cohort studies lent support for bracing to slow curve progression. One retrospective single-group cohort study suggested an association between yoga and reduced curve progression. Evidence for injections to reduce ADS symptoms was rated as low quality; evidence for bracing and yoga was rated as very low quality. No specific evidence was identified regarding other treatments, including physical therapy and analgesics. CONCLUSIONS: Literature describing the effectiveness of nonoperative treatments in symptomatic ADS is scarce. The quantity and quality of the evidence regarding injections, bracing, and yoga are insufficient to advise for or against the use of these methods to improve outcomes in symptomatic ADS. For these and other nonoperative treatment forms, further research is needed.

Electromyographic analysis of selected shoulder muscles during a series of exercises commonly used in patients with symptomatic degenerative rotator cuff tears.

BACKGROUND: In the nonoperative treatment of degenerative rotator cuff (RC) tears, exercise therapy is advocated. Exercises focusing on strengthening the anterior deltoid (AD) and the scapular muscles are proposed to compensate for RC dysfunction. However, the amount of electromyographic (EMG) activity in these muscles during these exercises remains unclear. Moreover, it is unknown whether muscle activity levels during these exercises alter with increasing age. Therefore, the purpose of this study was to evaluate EMG activity in the deltoid and scapular muscles during 2 series of commonly used shoulder rehabilitation exercises and assess possible age-related changes in muscle activity. METHODS: Fifty-five healthy participants (aged 18-60 years) participated in this study. Surface EMG activity was measured in 8 shoulder girdle muscles during a progression of a closed chain elevation program (bench and wall slides) and during a progression of previously published AD exercises. In addition, muscle activity was compared between 3 age categories (18-32 years, 33-46 years, and 47-60 years). RESULTS: The proposed progressions exhibited increasing activity from <10% of maximal voluntary isometric contraction to >20% of maximal voluntary isometric contraction for the AD for both exercise programs and for the middle deltoid, upper trapezius, and middle trapezius during the closed chain elevation exercises. Activity levels in the other muscles remained <20% throughout the progression. Age-related analysis revealed increased activity in the AD, infraspinatus, and middle trapezius and decreased lower trapezius activity during the bench and wall slides. No age-related changes were noted for the AD exercises. CONCLUSION: These findings may assist the clinician in prescribing appropriate progressive exercise programs for patients with symptomatic RC tears.

Operative versus nonoperative treatment of humeral shaft fractures: a systematic review and meta-analysis.

BACKGROUND: The humeral shaft fracture accounts for 1%-3% of all fractures and occurs in both the young and old population. However, the optimal treatment is still a matter of debate. Even though nonoperative treatment is commonly considered the gold standard, advantages have been described using operative stabilization. This systematic review aims to compare operative and nonoperative treatment in adult patients with humeral shaft fractures. METHOD: We used the following databases: PubMed, Embase, Cochrane, and CINAHL on October 1, 2018, searching for randomized controlled trials (RCTs) and cohort studies. Two reviewers screened the studies using Covidence, followed by systematic data extraction. The primary outcome was defined as posttreatment complications such as nonunion, radial nerve palsy, malunion, and infections. The secondary outcomes were functional scores and patient-reported outcome measures (PROMs). To assess study quality, the risk of bias in nonrandomized studies of interventions and the Cochrane risk of bias tool were used. RESULTS: Twelve studies were included: 1 RCT, 1 prospective cohort, and 10 retrospective cohorts with a total of 1406 patients, of whom 835 were treated operatively and 571 nonoperatively. Mean age ranged from 35 to 64, and 54% of the patients were male. The cohort studies had, in general, moderate bias, whereas the RCT had a low bias. There were statistically significant fewer nonunions in the operative treated group with a risk ratio of 0.49 (0.35-0.67), yielding a number needed to treat = 12. There were more deep infections in the operative group with a risk ratio of 2.76 (1.01-7.53) but otherwise no statistical differences concerning malunion or nerve damage. Only 1 study included PROM data. CONCLUSION: There were fewer nonunions in the operative group but more deep infections. Because of the lack of studies reporting PROMs, the potential positive effect of operative therapy in early aftercare could not be evaluated. Therefore, PROMs should be mandatory in future comparative studies.

The Functional Outcomes of Patients With Knee Osteoarthritis Managed Nonoperatively at the Joint Clinic at 5-Year Follow-Up: Does Surgical Avoidance Mean Success?

BACKGROUND: Nonoperative management of patients with knee osteoarthritis (OA) through multidisciplinary programs may delay or reduce the need for total knee arthroplasty (TKA). However, avoidance of surgery may not represent success for the patient. METHODS: A cohort of 120 patients with knee OA managed with at least 6 months of supervised nonoperative treatment coordinated through the Joint Clinic were reviewed at 5 years. Outcomes including Oxford knee score (OKS), Short Form 12 (SF-12), and SF-6D and other measures including analgesia use, global change, and perception of need for surgery were collected and compared with those from the cohort who had undergone TKA. RESULTS: Seventy (62.5%) surviving patients were still being managed nonoperatively. There was no significant change in any outcome score (OKS, SF-12 physical component score, SF-12 mental component score, SF-6D) (P = .26 to .84). Forty-two patients had undergone TKA with mean time to surgery 29.0 months (range, 9-69 months). In this group, the mean OKS fell from 17.9 at baseline to 10.3 (range, 3-21) preoperatively (P < .0001) and at 5 years there was a significant improvement from baseline in OKS, SF-12 physical component score, and SF-6D scores (P < .0001). All outcome scores and change in scores were significantly higher for the surgical group (all P < .001). CONCLUSION: Although a high proportion of patients with knee OA have avoided surgery at 5 years, their outcomes show no improvement from baseline and are poorer than those who have undergone TKA. Avoidance of surgery should not necessarily be regarded as an indicator of success of nonoperative treatment for the patient.