Current Concepts

Background: Osteochondritis dissecans (OCD) of the capitellum is a painful condition, which often affects young throwing athletes. Our current understanding regarding the etiology, risks factors, diagnosis, and efficacy of the available treatment options has expanded over recent years, however remains suboptimal. Recent data on patient-reported outcomes following osteochondral autograft transplantation (OAT) for the treatment of large osteochondral lesions of the capitellum have been promising but limited. This review seeks to critically analyze and summarize the available literature on the etiology, diagnosis, and reported outcomes associated with OCD of the capitellum and the use of OAT for its treatment. Methods: A comprehensive literature search was conducted. Unique and customized search strategies were formulated in PubMed, Embase, Scopus, Web of Science, and CENTRAL. Combinations of keywords and controlled vocabulary terms were utilized in order to cast a broad net. Relevant clinical, biomechanical, anatomic and imaging studies were reviewed along with recent review articles, and case series. Results: Forty-three articles from our initial literature search were found to be relevant for this review. The majority of these articles were either review articles, clinical studies, anatomic or imaging studies or biomechanical studies. Conclusions: Current evidence suggests that OAT may lead to better and more consistent outcomes than previously described methods for treating large OCD lesions of the capitellum.

Download Full-text

Management of feline carpal injuries: What are the options and when is arthrodesis indicated?

Journal of Feline Medicine and Surgery ◽

10.1177/1098612x19870388 ◽

2019 ◽

Vol 21 (9) ◽

pp. 809-823 ◽

Cited By ~ 1

Author(s):

Rachel M Basa ◽

Kenneth A Johnson

Keyword(s):

Treatment Options ◽

Case Series ◽

Evidence Base ◽

Careful Examination ◽

Current Evidence ◽

Collateral Ligament ◽

Retrospective Case ◽

Radial Collateral Ligament ◽

Current Evidence Base ◽

Direct Extrapolation

Practical relevance: Feline carpal injuries are usually caused by falls from a height that result in hyperextension injury or antebrachiocarpal luxation or subluxation. Isolated ligamentous damage or fracture of the carpus is unusual; it is more common to have a combination of both in the cat. These injuries can be debilitating since cats climb and jump from great heights, and have a greater range of antebrachial pronation and supination than dogs. Anatomy: There are differences in the anatomy of the feline and canine carpus. In particular, cats only have a single short radial collateral ligament, also known as the medial collateral ligament. This means that, in the cat, antebrachiocarpal subluxation is possible with rupture of the dorsal joint capsule and short radial collateral ligament alone. Clinical challenges: Many feline carpal injuries can be treated without performing pancarpal arthrodesis. However, determining which ligaments and joint levels are affected requires careful examination and often stress radiography. When pancarpal arthrodesis is performed in the cat, it has been reported to reduce the height of jumping and to increase reluctance to climb. This is speculated to be due to reduced pronation and supination movement of the carpus. Evidence base: The current evidence base for management of feline carpal injuries is grade III or IV, with most of the studies being retrospective case series involving cadaveric dissection or direct extrapolation from published information about the dog. There are few guidelines regarding the optimal treatment options for carpal injuries in the cat.

Download Full-text

Need for standard outcome reporting systems in craniosynostosis

Neurosurgical FOCUS ◽

10.3171/2011.6.focus1192 ◽

2011 ◽

Vol 31 (2) ◽

pp. E1 ◽

Cited By ~ 18

Author(s):

Caroline Szpalski ◽

Katie Weichman ◽

Fabio Sagebin ◽

Stephen M. Warren

Keyword(s):

Health Care Professionals ◽

Treatment Options ◽

Case Series ◽

Functional Results ◽

Series Data ◽

Quality Level ◽

Complication Rates ◽

Outcome Reporting ◽

Radiographic Measurements ◽

Patient Reported

Craniosynostosis is the premature fusion of one or more cranial sutures. When a cranial suture fuses prematurely, skull growth is altered and the head takes on a characteristic pathological shape determined by the suture(s) that fuses. Numerous treatment options have been proposed, but until recently there were no parameters or guidelines of care. Establishing such parameters was an important step forward in the treatment of patients with craniosynostosis, but results are still assessed using radiographic measurements, complication rates, and ad hoc reporting scales. Therefore, clinical outcome reporting in the treatment of craniosynostosis is inconsistent and lacks methodological rigor. Today, most reported evidence in the treatment of craniosynostosis is level 5 (expert opinion) or level 4 (case series) data. Challenges in obtaining higher quality level 1 or level 2 data include randomizing patients in a clinical trial as well as selecting the appropriate outcome measure for the trial. Therefore, determining core outcome sets that are important to both patients and health care professionals is an essential step in the evolution of caring for patients with craniosynostosis. Traditional clinical outcomes will remain important, but patient-reported outcomes, such as satisfaction, body image, functional results, and aesthetic outcomes, must also be incorporated if the selected outcomes are to be valuable to patients and families making decisions about treatment. In this article, the authors review the most commonly used tools to assess craniosynostosis outcomes and propose a list of longitudinal parameters of care that should be considered in the evaluation, diagnosis, and treatment evaluation of a patient with craniosynostosis.

Download Full-text

Surgical Treatment of Neuroendocrine Liver Metastases

International Journal of Hepatology ◽

10.1155/2012/146590 ◽

2012 ◽

Vol 2012 ◽

pp. 1-13 ◽

Cited By ~ 6

Author(s):

Ser Yee Lee ◽

Peng Chung Cheow ◽

Jin Yao Teo ◽

London L. P. J. Ooi

Keyword(s):

Liver Metastases ◽

Treatment Options ◽

Case Series ◽

Current Evidence ◽

Progression Rate ◽

Term Survival ◽

Management Algorithm ◽

Pubmed Database ◽

Neuroendocrine Liver Metastases

Management of Neuroendocrine liver metastases (NELM) is challenging. The presence of NELM worsens survival outcome and almost 10% of all liver metastases are neuroendocrine in origin. There is no firm consensus on the optimal treatment strategy for NELM. A systematic search of the PubMed database was performed from 1995–2010, to collate the current evidence and formulate a sound management algorithm. There are 22 case series with a total of 793 patients who had undergone surgery for NELM. The overall survival ranges from 46–86% at 5 years, 35–79% at 10 years, and the median survival ranges from 52–123 months. After successful cytoreductive surgery, the mean duration of symptom reduction is between 16–26 months, and the 5-year recurrence/progression rate ranges from 59–76%. Five studies evaluated the efficacy of a combination cytoreductive strategy reporting survival rate of ranging from 83% at 3 years to 50% at 10 years. To date, there is no level 1 evidence comparing surgery versus other liver-directed treatment options for NELM. An aggressive surgical approach, including combination with additional liver-directed procedures is recommended as it leads to long-term survival, significant long-term palliation, and a good quality of life. A multidisciplinary approach should be established as the platform for decision making.

Download Full-text

A systematic review on conservative and non-operative treatment options for Osgood-Schlatter disease

10.31236/osf.io/u4vn7 ◽

2020 ◽

Author(s):

Cornelia Neuhaus ◽

Christian Appenzeller-Herzog ◽

Oliver Faude

Keyword(s):

Systematic Review ◽

Operative Treatment ◽

Treatment Options ◽

Grey Literature ◽

Case Series ◽

Outcome Data ◽

Control Group ◽

Retrospective Case ◽

Review Articles ◽

Knee Pathology

Background: Osgood-Schlatter disease (OSD) is a sport- and growth-associated knee pathology with painful osteochondrosis around the tibial tuberosity. Up to 10% of adolescents are affected by OSD. Treatment is primarily conservative or non-operative and includes injections, ice, braces, casts, tape and/or physiotherapy. However, treatment outcomes are often insufficiently described and there is lack of evidence for current best practice.Objective: The aims of this systematic review are to comprehensively identify conservative or non-operative treatment options for OSD, to compare their effectiveness in selected outcomes, and to describe potential research gaps. and to describe potential research gaps.Methods: This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. CENTRAL, CINAHL, EMBASE and MEDLINE via Ovid, and PEDro were searched through to January 6, 2020. In addition, ongoing and unpublished clinical studies, dissertations, and other grey literature on OSD were retrieved. We included prospective, retrospective, case control, randomised, and non-randomised studies reporting on the effectiveness of any conservative or non-operative treatment of 6- to 28-year-old OSD patients. Studies written in English, German, or French were included. The quality of the included studies was assessed using the PEDro scale and extracted outcome data were narratively synthesized. In addition, we also systematically retrieved review articles for extraction of treatment recommendations.Results: Of 767 identified studies, thirteen were included: two randomised controlled trials (RCTs), two prospective and eight retrospective observational studies, and one case series. Eight studies had no control group. The included studies were published from 1948 to 2019 and included 747 patients (563 male, 119 female, 65 sex not reported) with 937 affected knees. The study quality was poor to moderate. The two included RCTs examined the effectiveness of surplus dextrose-injection in OSD patients treated with local anaesthetics injection and came to opposite conclusions. Other than that, inter-study heterogeneity prohibited any descriptive cumulative analyses. Among the 15 review articles, the most prevalent treatment recommendations were activity modification (15/15), quadriceps and hamstring stretching (13/15), medication (11/15), ice (11/15), strengthening of the quadriceps (9/15), and knee straps or brace (8/15).Conclusion: Conflicting evidence exists to support the use of dextrose injections. Certain therapeutic approaches, such as stretching, seem to work, but no RCT comparing specific exercises with sham or usual care treatment exists. Carefully controlled studies on well- described treatment approaches are needed to establish which conservative or non-operative treatment options are most effective for patients with OSD.

Download Full-text

Outcomes of Surgical Treatment of Talar Osteochondral Lesions using Bone Marrow Aspirate and Microgenized Allograft Cartilage Extra-cellular Matrix

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00210 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0021

Author(s):

Robert Dekker ◽

Milap Patel

Keyword(s):

Bone Marrow ◽

Surgical Treatment ◽

Functional Outcomes ◽

Bone Marrow Aspirate ◽

Case Series ◽

Cartilage Matrix ◽

Osteochondral Lesions ◽

Measurement Information ◽

Significant Difference ◽

Patient Reported

Category: Sports Introduction/Purpose: Osteochondral lesions (OCL) of the talus are frequently seen after ankle injury and often result in significant morbidity. Apart from a single case report, we are the first to present a case series of OCLs treated with bone marrow aspirate and micronized extracellular allograft cartilage matrix designed to serve as a scaffold to promote autologous healing. Short to mid-term outcomes using this technique are virtually absent in the literature. In this study, we sought to assess pre- and post-procedural functional outcomes using the validated Patient Reported Outcomes Measurement Information System (PROMIS) as well as assess cartilage incorporation on postoperative ankle MRI using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring. Methods: Twelve patients with symptomatic talar OCLs (14 lesions) were prospectively recruited. Average age was 44 years. Each underwent ankle arthroscopy, ankle arthrotomy, marrow stimulation and lesion repair using BMA and micronized extracellular allograft cartilage matrix by a single fellowship trained foot and ankle Orthopedic Surgeon. Preoperative, 6 month and 1 year postoperative PROMIS pain and function scores were collected prospectively. At six months, all patients underwent ankle MRI scans that were reviewed by a fellowship trained musculoskeletal radiologist for MOCART scoring. Results: No significant difference was detected between mean pre- and postoperative PROMIS function (41.4 vs 38.1; p=.54) and pain (61.3 vs 66.1) scores at 6 months. No significant difference was seen between mean pre- and postoperative PROMIS function (41.4 vs 41.8; p=.93) and pain (61.3 vs 58; p=.48) scores at 1 year. Mean postoperative MOCART score was 53.2 with a range of 5 to 90. Conclusion: Bone marrow aspirate and extracellular allograft cartilage matrix for surgical treatment of talar OCL showed no statistically significant improvement in functional outcomes at 6 months and 1 year. No correlation between functional outcomes and MOCART score was seen.

Download Full-text

The Role of Arthroscopic Debridement after Ankle Fractures Treated with ORIF

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000125 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0001

Author(s):

Paolo Ceccarini ◽

Giuseppe Rinonapoli ◽

Julien Teodori ◽

Auro Caraffa

Keyword(s):

Distal Tibia ◽

Case Series ◽

Activity Level ◽

Ankle Arthroscopy ◽

Ankle Fractures ◽

Osteochondral Lesions ◽

Operation Rate ◽

Patient Reported

Category: Ankle, Ankle Arthritis, Arthroscopy Introduction/Purpose: The role of ankle arthroscopy in managing the consequences of ankle fractures is yet to be fully estab- lished. This study aims to assess this procedure in terms of the accuracy of preoperative diagnosis, re-operation rate and patient- reported outcomes. Methods: We compared two homogeneous groups of 16 patients (32 in total, average age 40.6 years) operated for a fracture of the distal tibia and/or fibula treated with ORIF. For all fractures the AO classification was used. The baseline was 6 months after surgery. Inclusion criteria were: patients aged between 19 and 50 a pre-trauma Tegner score >3, FAOS score <75 at the baseline, R.O.M. <20° vs contralateral; we included patients with well-aligned osteosynthesis and with radiographic union. Patients with open fractures, with osteochondral lesions and with previous were excluded. In the first group we planned an arthroscopy of the ankle from 6 to 12 months after trauma, in the second group, we continued with conservative rehabilitation treatment. All patients were then re-evaluated at 3,6 and 12 months with questionnaires (Tegner activity level, and FAOS). The mean follow-up was 18.2 months. For all data statistical analysis was performed. Results: The results of our case-series showed excellent patient satisfaction (12/14) with a FAOS Score and an improved R.O.M. statistically significant (p <.001) in patients treated with ankle arthroscopy. Eighty percent was able to return to previous activity. The average time until return to sport was 5.3 ± 2.4 months. Seventy percent of the athletes still had occasional pain with sport. Conclusion: The literature on arthroscopic treatment after fracture is still poor but results obtained, even with a limited number of cases, and with a short follow-up, are positive, especially in those patients where the functional demand is highest.

Download Full-text

Patient-Reported Outcomes After Structural Autograft for Large or Cystic Talar Dome Osteochondral Lesions

Foot & Ankle International ◽

10.1177/1071100720907313 ◽

2020 ◽

Vol 41 (5) ◽

pp. 549-555

Author(s):

Todd Kim ◽

Andrew Haskell

Keyword(s):

Patient Reported Outcomes ◽

Distal Tibia ◽

Case Series ◽

Osteochondral Lesions ◽

Measurement Information ◽

Talar Dome ◽

Level Of Evidence ◽

Structural Bone Graft ◽

Patient Reported

Background: While smaller talar dome osteochondral lesions (OCLs) are successfully treated with bone marrow stimulation techniques, the optimal treatment for large or cystic OCLs remains controversial. This study tested the hypothesis that transferring structural autograft bone from the distal tibia to the talus for large or cystic OCLs improves pain and function. Methods: Thirty-two patients with large or cystic OCLs underwent structural bone grafting from the ipsilateral distal tibia to the talar dome. Patients were assessed with subjective patient-centered tools and objective clinical outcomes. Average age was 48.6 ± 14.9 years, and average follow-up was 19.5 ± 13.3 months. Average lesion area was 86.2 ± 23.5 mm2, and average depth was 8.4 ± 3.0mm. Results: At final follow-up, improvement compared to preoperative scores was seen in American Orthopaedic Foot & Ankle Society (65.4 ± 21.2 to 86.9 ± 15.0, P < .05), Foot Function Index (48.9 ± 20.8 to 21.1 ± 18.9, P < .05), visual analog scale for pain (4.7 ± 3.0 to 1.4 ± 1.5, P < .05), and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (40.4 ± 5.4 to 45.5 ± 7.4, P < .05) scores. There was no improvement in PROMIS pain interference (54.7 ± 18.1 to 52.4 ± 7.3, P > .05). Satisfaction with surgery was 8.4 ± 1.3/10, and 96% of patients would have the procedure again. Ninety-four percent of patients returned to work and/or play. One patient had a deep vein thrombosis 6 weeks postoperatively, and 1 patient underwent ankle fusion at 18 months postoperatively. Conclusion: This study demonstrates that structural bone graft harvested from the distal tibia transferred to the talus was a safe and effective treatment for large and cystic OCLs. Outcomes compare favorably to other described techniques for treatment of these injuries. Level of Evidence: Level IV, case series.

Download Full-text

Patients’ values and other decisional factors regarding treatment of hypercalcemia of malignancy: A Systematic Review Protocol

10.21203/rs.3.rs-64830/v2 ◽

2021 ◽

Author(s):

Aya Bassatne ◽

Maya Rahme ◽

Thomas Piggott ◽

Mohammad H Murad ◽

Layal Hneiny ◽

...

Keyword(s):

Systematic Review ◽

Observational Studies ◽

Drug Class ◽

Treatment Options ◽

Case Series ◽

Pharmacological Therapy ◽

Current Evidence ◽

Drug Selection ◽

Hypercalcemia Of Malignancy ◽

Review Protocol

Abstract Background: Hypercalcemia of malignancy is the second most common cause of hypercalcemia and is associated with significant morbidity and mortality. Several treatment options are available including pharmacological therapy with bisphosphonates, denosumab, glucocorticoids, and calcimimetics, as well as conventional therapy with hydration and possibly calcitonin. While guidelines have previously considered treatment effects, no guideline has yet considered a range of contextual factors impacting recommendations for the management. Objective: The aim of this study is to summarize the available evidence on important decisional factors for the development of guidelines for the treatment of hypercalcemia of malignancy. These include patient’s values and preferences, cost, acceptability, feasibility, and equity. Methods/Design: This is a systematic review of observational studies, case series, trials, reviews and qualitative studies involving treatment of adult patients with hypercalcemia of malignancy. We developed and executed two independent search strategies using five databases: Pubmed, Medline (OVID), Embase.com, CINAHL (EBSCO) and Cochrane, and reviewed their combined output. Two reviewers screened titles and abstracts and full texts and will implement data abstraction from relevant studies independently and in duplicate. The outcomes of interest are the decisional factors that influence drug selection, with possible subgroup analyses by drug class or etiology of hypercalcemia of malignancy. We will present the data collected in a narrative and thematic approach. Discussion: This systematic review will identify important treatment decisional factors, and will assist guidelines panels, physicians and patients to decide on therapeutic options based on the current evidence.

Download Full-text

Surgery and Conservative Management of Camptodactyly in Pediatric Patients: A Systematic Review

Hand ◽

10.1177/1558944719834654 ◽

2019 ◽

Vol 15 (6) ◽

pp. 761-770

Author(s):

Annie M. Q. Wang ◽

Min Kim ◽

Emily S. Ho ◽

Kristen M. Davidge

Keyword(s):

Systematic Review ◽

Patient Care ◽

Conservative Management ◽

Case Series ◽

Flexion Contracture ◽

Current Evidence ◽

Future Research ◽

Global Rating ◽

Patient Reported ◽

Definition Of

Camptodactyly is a pediatric hand condition, the treatment of which remains controversial. The authors’ aim was to improve patient care through clarifying the definition of camptodactyly and indications for surgical and/or conservative management, summarizing outcomes, and defining risks. A systematic review was conducted of articles in all languages on outcomes following surgical and/or conservative management of idiopathic camptodactyly in children using MEDLINE (Medical Literature Analysis and Retrieval System Online), PubMed, EMBASE (Excerpta Medica database), AMED (Allied and Complementary Medicine), and CINAHL (Cumulative Index of Nursing and Allied Health Literature) (until January 2017). The primary outcome was posttreatment flexion contracture, and the secondary outcomes were indications for surgery, complications, and patient satisfaction. Database searching generated 16 final articles, with 7 case series and 9 retrospective cohort studies. There was a lack of consistency on the definition of camptodactyly and in outcome reporting. All 16 studies received a “Weak” global rating and demonstrated low-quality evidence, suggesting that treatment of camptodactyly with operative or nonoperative measures reduces the degree of flexion contracture in most patients (from pretreatment averages of 20°-85° to posttreatment averages of 5°-37°). There was general agreement that surgery should be reserved for contracture >30° or failure to respond to conservative management. Surgery generally led to more complications compared with conservative management. Only one study reported on functional limitations, and another reported on patient-reported outcomes. Current evidence of the effectiveness of camptodactyly treatment in addressing both joint-specific deformity and patient-perceived function and appearance is insufficient to guide patient care. Future research may consider the development of decision aids to guide patients and families through selecting management strategies and to promote shared decision making.

Download Full-text

Case study: An evidence based approach to the use of dry needling for a concussion within the cervicogenic pathway

Neurology ◽

10.1212/01.wnl.0000550695.45926.d3 ◽

2018 ◽

Vol 91 (23 Supplement 1) ◽

pp. S18.2-S18

Author(s):

Kristina Green ◽

Hollie Walusz ◽

Stephanie Naylor

Keyword(s):

Clinical Practice ◽

Clinical Pathways ◽

Treatment Options ◽

Current Evidence ◽

Dry Needling ◽

Concussion Management ◽

Patient Reported ◽

Intervention Modality ◽

Safety Considerations ◽

The Impact

Concussion management and treatment continues to be a popular topic of current literature. As discussion of concussion pathways continues to be highlighted, specific intervention strategies are gaining popularity as best treatment options. For patients that fall into the cervicogenic pathway of concussion, DN is an intervention modality that is becoming more prevalent in its use. This presentation will describe the common presentation of patients that fall within this concussion pathway and highlight how DN reduces pain and disability within this subset of patients. We will discuss the current evidence and efficacy of DN as an intervention tool in our clinical practice, specifically for the cervicogenic pathway of concussion. We will outline and demonstrate proper application procedures for DN within the cervical, occipital and temporal regions with discussion of safety considerations. We will then correlate this intervention tool with the use of outcome measures within clinical practice and tie it back to patient reported concussive symptoms. Finally, we will discuss the impact on time to resolution of symptoms DN can have in our patients. Learning Objectives: (1) Discuss the theory of Concussion Clinical Pathways. (2) Understand a specific clinical presentation of a patient within the Cervicogenic Pathway. (3) Define Dry Needling (DN). (4) Understand the utilization and pathophysiology behind DN in clinical practice. (5) Understand the proper application of DN in the cervical, occipital and temporal regions. (6) Recognize the benefit DN has on this specific pathway. (7) Recognize patients that can benefit from this intervention through the use of a case presentation.

Download Full-text