Functional outcome 5 years after non-operative treatment of type A spinal fractures

This study was conducted to study the functional outcome after non-operative treatment of type A thoracolumbar spinal fractures without neurological deficit. Functional outcome was determined following the International Classification of Functioning, Disability and Health, measuring restrictions in body function and structure, restrictions in activities, and restrictions in participation/quality of life. All patients were treated non-operatively for a type A thoracolumbar (Th11-L4) spinal fracture at the University Hospital Groningen, The Netherlands. Thirty-three of the eighty-one selected patients agreed to participate in the study (response-rate 41%). Respondents were older than non-respondents (mean 50.5 years vs. 39.2 years), but did not differ from each other concerning injury-related variables. Patients with a neurological deficit were excluded. Treatment consisted either of mobilisation without brace, or of bedrest followed by wearing a brace. Restrictions in body function and structure were measured by physical tests (dynamic lifting test and bicycle ergometry test); restrictions in activities were measured by means of questionnaires, the Roland Morris Disability Questionnaire (RMDQ) and Visual Analogue Scale Spine Score (VAS). Restrictions in participation/quality of life were assessed with the Short Form 36 (SF-36) and by means of return to work status. Thirty-seven per cent of the patients were not able to perform the dynamic lifting test within normal range. In the ergometry test, 40.9% of the patients performed below the lowest normal value, 36.4% of the patients achieved a high VO₂-max. Mean RMDQ-score was 5.2, the mean VAS-score was 79. No significant differences between patients and healthy subjects were found in SF-36 scores, neither were differences found between braced and unbraced patients in any of the outcome measures. Concerning the return to work status, 10% of the subjects had stopped working and received social security benefits, 24% had arranged changes in their work and 14% had changed their job. We conclude that patients do reasonably well 5 years after non-operative treatment of a thoracolumbar fracture, although outcome is diverse in the different categories and physical functioning seems restricted in a considerable number of patients.     

急性踝关节外侧副韧带损伤手术与非手术治疗的Meta分析

目的 对手术治疗和非手术治疗急性踝关节外侧副韧带损伤的疗效与术后并发症进行Meta分析. 方法 计算机检索MEDLINE(从1966年至2011年10月)、EMbase(从1988年1月至2011年10月)、中国生物医学文献数据库(从1978年1月至2011年10月)和中国知网数据库(从1980年1月至2011年10月),收集比较手术治疗和非手术治疗急性踝关节外侧副韧带损伤的随机对照试验(RCT)、临床对照试验、半随机对照试验、队列研究等,评价纳入研究的方法学质量,并提取有效数据进行Meta分析,以比较手术治疗与非手术治疗后踝关节活动水平恢复、踝关节功能稳定性、踝关节损伤复发、踝关节残留疼痛及治疗后并发症的差异. 结果 纳入13个RCTs,其中手术治疗713例,非手术治疗817例.Meta分析显示,手术治疗踝关节功能稳定性显著优于非手术治疗[OR=0.72,95％ CI (0.52,0.99),P＜0.05],手术治疗踝关节强直的发生率[OR=3.41,95％ CI为(1.56,7.44)]显著高于非手术治疗.手术治疗与非手术治疗关节活动水平恢复[0R=1.14,95％ CI(0.58,2.21)]、踝关节损伤复发[OR=0.68,95％ CI(0.35,1.31)]、残留疼痛[OR=0.81,95％ CI(0.56,1.16)]、关节活动障碍[OR=2.38,95％ CI(0.91,6.25)]发生率差异均无统计学意义(P＞0.05).手术治疗损伤部位瘢痕[OR=7.46,95％ CI(1.32,42.08),P＜0.05]和感觉神经丧失[OR=12.16,95％ CI(2.24,66.02),P＜0.05]发生率均高于非手术治疗,手术治疗并发症总发生率显著高于非手术治疗[0R=6.20,95％ CI(2.67,14.41),P＜0.05]. 结论 手术治疗急性踝关节外侧副韧带损伤与非手术治疗相比,能显著提高踝关节稳定性,但踝关节活动水平的恢复、损伤复发和关节残留疼痛无显著差异,且会增加并发症发生的风险.     

Paediatric duodenal haematoma: Nonoperative management of blunt traumatic injury

Trauma is the leading cause of morbidity and mortality in the paediatric population. Following the head and extremities, the abdomen is the third most commonly injured anatomic region in children [1]. We present a case of a massive duodenal haematoma secondary to blunt trauma that was managed nonoperatively. Several cases reports in the literature cite successful nonoperative management of duodenal haematoma by nasogastric decompression, bowel rest, and total parenteral nutrition [4], with resumed eating an average of 16 days after injury [9]. However, if the abdominal pain or obstruction fail to improve and/or resolve with medical management over seven to ten days, complications such as infarction or peritonitis are frequent, and surgical intervention may be required [3].     

Towards a non-operative strategy for severe blunt pancreatic injury—Case report

BackgroundPancreatic injury remains uncommon and the majority occurs in association with injury of other organs. For years, surgery has been advised for those with evidence of pancreatic duct damage. However, a lot of changes were seen in the management of blunt abdominal trauma, with strong support for non-operative management of solid organ injuries. There is strong evidence from paediatric patients that those with severe pancreatic contusion and ductal injury can be managed conservatively.Patients and methodWe present our cases of severe blunt pancreatic injury with ductal damage that were successfully managed non-operatively. We reviewed the literature to find evidence to support this management strategy.ResultOur case report and the literature showed that majority of pancreatic ductal injury have been successfully managed non-operatively without increased morbidity or mortality.ConclusionNon-operative management of blunt pancreatic injury with ductal damage allows the formation of a pseudocyst for delayed drainage safely. This strategy of “induced pseudocyst” is particularly applicable to cases that present late and those with concomitant injuries of other organs. The majority of pseudocysts will subside by themselves. The use of embolization may decrease the need for urgent operation and timely percutaneous drainage may help relieve early symptoms.     

半月板部分切除和非手术治疗膝内侧半月板退行性损伤的对比研究

目的比较关节镜下半月板部分切除和系统非手术治疗退行性膝关节内侧半月板损伤的临床疗效。方法采用前瞻性研究方法,选取2016年8月至2017年6月首都医科大学附属北京友谊医院骨科收治的退行性膝关节内侧半月板损伤患者62例,所有患者均接受膝关节磁共振检查证实为退行性膝关节内侧半月板损伤。按照单纯随机抽样法将患者分为手术治疗组和非手术治疗组,每组各31例。手术治疗组患者接受关节镜下膝关节内侧半月板部分切除,非手术治疗组患者采用口服非甾体抗生素、冲击波和运动疗法治疗。治疗前和治疗后6个月分别使用膝关节损伤和骨关节炎结果评分(KOOS评分)、Tegner活动度评定量表(Tegner评分)和Lysholm膝关节评分(Lysholm评分)评价膝关节功能和疼痛程度,并且比较两种方法的治疗效果。结果截止到2018年1月,除3例患者失访外,59例患者获得完整门诊随访,其中手术治疗组30例,非手术治疗组29例。手术组治疗前KOOS评分、Tegner活动度评定量表评分和Lysholm膝关节评分分别为(308.8±11.2)分,(3.3±1.2)分和(65.2±9.6)分;而非手术治疗组治疗前上述指标分别为(306.7±10.3)分,(3.4±1.3)分和(64.8±8.1)分;两组各评分比较差异无统计学意义(P>0.05)。治疗6个月后,手术组患者KOOS评分、Tegner活动度评定量表评分和Lysholm膝关节评分分别为(310.6±10.8)分、(3.5±1.3)分、(65.2±9.6)分,非手术治疗组上述指标分别为(359.1±18.4)分、(4.6±1.7)分、(73.2±10.1)分,非手术组各评分均明显优于手术组,差异有统计学意义(P<0.05)。非手术组优良率(72.4%)明显高于手术组(46.7%),差异具有统计学意义(P<0.05)。结论对于退行性膝关节内侧半月板损伤,系统非手术治疗的效果优于关节镜下半月板部分切除的临床疗效,所以首选推荐使用系统的非手术治疗方法。     

Pulmonary embolism following ankle fractures treated without an operation – An analysis using National Health Service data

The majority of ankle fractures are stable and can be treated without an operation, most commonly with cast immobilisation. Based on concerns regarding the risk of a venous thromboembolic event (VTE) while immobilised, there is currently debate as to whether these patients should receive VTE prophylaxis for the duration of treatment. Rates of pulmonary embolism (PE) in this patient group are unknown. This retrospective cohort study was designed to identify patients treated without an operation for ankle fracture and determine the occurrence of PE and inpatient mortality within 90 days of injury using the English National Health Service administrative databases. Logistic regression models were used to assess the influence of age, gender and Charlson co-morbidity score on these outcomes.     

Splenic artery embolisation in children and adolescents—An 8 year experience

Background

Non-operative management (NOM) is the treatment of choice in blunt splenic injuries in the paediatric population, with reported success rates exceeding 90%. Splenic artery embolisation (SAE) was added to our institutional treatment protocol for splenic injury in 2002. We wanted to review indications for SAE and the clinical outcome of splenic injury management in children admitted between August 1, 2002 and July 31, 2010.

Methods

Patients aged <17 years with splenic injury were identified in the institutional trauma and medical code registries. Patient charts and computed tomographic (CT) scans were reviewed.

Results

Of the 72 children and adolescents with splenic injury included during the 8 year study period, 66 patients (92%) were treated non-operatively and six underwent operative management. Severe splenic injury (OIS grade 3–5) was diagnosed in 67 patients (93%). SAE was performed in 22 of the NOM patients. Indications for SAE included – bleeding (n = 8), pseudoaneurysms (n = 2), contrast extravasation (n = 2), high OIS injury grade (n = 8) and prophylactic due to specific disease (n = 2). NOM was successful in all but one case (98%). For the patients aged ≤14 years, extravasation on initial CT scan correlated to delayed bleeding (p < 0.001). Two SAE procedure specific complications were registered, but resolved without significant sequelae.

Conclusion

After SAE was added to the institutional treatment protocol, 22 of 66 NOM paediatric patients underwent SAE. NOM was successful in 98% and a 90% splenic preservation rate was achieved. Contrast extravasation correlated to delayed splenic bleeding in children ≤14 years.     

Conservative management of a splenic cyst

The case of a child found to have an asymptomatic splenic cyst is presented.The child was managed conservatively with eventual resolution of the cyst.     

Medium-term clinical results after operative and non-operative treatment of subacromial impingement

Summary Treatment of subacromial outlet impingement can be operative or non-operative. The purpose of this prospective study was to compare the results of these two types of treatment over a fairly long period. To this end, 72 patients suffering from grade II outlet impingement were prerandomized into two different groups. Group I was made up of 32 patients who were treated operatively; the 40 patients in group II underwent a non-operative treatment. Follow-up time was 4 years for both groups. Depending on the surgeon an arthroscopic subacromial decompression according to Ellman or an anterior acromioplasty according to Neer was performed in each patient in group I. During a 2-week hospital stay a non-operative treatment was administered to all patients in group II. Before the start of treatment patient evaluation was performed: clinical examination, transscapular, a. p. and oblique X-rays, ultrasonography and the LA test; in addition, the Subjective Shoulder Rating Scale (SSRS) was used. This is basically a modification of the Constant-Murley Scoring System. The patients were familiarized with the SSRS sheet before starting the treatment. The sheet was mailed to the patients for then to evaluate their shoulders at yearly intervals. The median total score in group I started from a lower level, with 54 points. The non-operativ median total score in group II started at 59 points. During the 4-year follow-up the improvement in the operatively treated shoulders was 30 points and that in the non-operatively treated shoulders, 15 points. Over the years there was a tendency for the operatively treated shoulders to improve. The pain score in group I improved from 10 points preoperatively to 25 points 1 year postoperatively and to 30 points in the 2nd, 3rd and 4th years after the operation. In group II the pain score declined. An increase of 5 points was found in the first 2 years after starting the treatment, and the same score, 20 points, as at the start was found in the 3rd and 4th years. The range of motion changed from 20 to 30 points only in group I. The activity score paralled the range of motion. Ability to work overhead was consistently reduced throughout the follow-up period and was not influenced by the treatment received. Instability was not a problem for these patients. There was no change in the scores in the two groups. In summary, both forms of treatment led to an improvement of the subacromial impingement. The improvement in pain was the most marked. The long-term results are required for the final evaluation, because results tend to change after both operative and non-operative treatment. In addition, clinical examination and diagnostic imaging techniques should be applied and are necessary to find the reasons for this change.